 Good evening, everybody. Thank you for being here for the Harvard Medical School Center for Bioethics public forum this evening. I know you have many options on Zoom these days, so I appreciate being here. I think it's going to be a terrific session. This is part of the Contemporary Books and Bioethics course that we have for the Master of Bioethics program at the Center for Bioethics. This is the second book we're doing this semester. It's Dr. Steve Miles, The Torture Doctors. And as you know, the session is being recorded. Just to orient you at the bottom of your screen, you're going to see a chat box and a Q&A box. So the chat box is live for everybody. You'll be able to see what everybody is saying, and we encourage you using that for dialogue with each other. The Q&A box is where the moderators and Dr. Miles will be looking for topics to address during the discussion section. So any particular things that you would like him to talk about, make sure that you put it in the Q&A box. This is about the fifth or sixth year. We've had the Contemporary Books and Bioethics course. And up until this year, I had the pleasure of teaching it with Dr. Wes Boyd. He's still on our faculty, but he has moved much of his activities to Texas and to Baylor University. But he's sort of making a reprise performance here, not only because he misses me, but also because he has a real specific interest in the work that Dr. Miles has done. And so I'm going to turn it over to Wes to introduce Dr. Miles and the session this evening. Thanks, Wes. Thank you, Bob. I consider this course, by the way, to be the showcase course in the master's program in bioethics here at Harvard. And I was incredibly honored to be able to co-teach it with Bob for the last five years. And no longer teaching it is actually one of the singular regrets I have about my recent move to Texas, even more than giving up my season tickets to the Celtics. I might have felt differently had the Celtics won it all last season, but they didn't. About tonight's speaker, I'm incredibly honored to be able to introduce Dr. Steve Miles. For decades, Dr. Miles has kept sharp focus on the role of health care workers in torture and has been one of my heroes. Dr. Miles is a profile in courage. After 9-11, the entire US, so it seemed, supported any and all efforts to interrogate enemy combatants, including techniques that constituted torture by any definition. At that time, speaking out against any element of US policy, whose purported goal was to extract information from terrorists, was frequently labeled un-American or even pro-terrorist. Despite that climate, Dr. Miles forged ahead with a strong moral compass and shined a light on the underbelly of our war on terror at a time when very few in the academy, including few in bioethics, were doing so. Doing what Dr. Miles did took guts and continues to do, takes guts. And it also required having a moral vision that transcended the sentiments of the day. The book he will speak about this evening, The Torture Doctors, documents and memorializes the extensive worldwide participation of physicians in torture. Physicians are supposed to heal, but Dr. Miles knows more than just about anyone else at times they can and do exactly the opposite. Dr. Miles is a retired internist and geriatrician, professor emeritus in bioethics and medicine at the University of Minnesota Medical School, and for many years held the endowed chair there in bioethics. He is the recipient of numerous awards for his work in medical ethics and human rights. When I asked him what he'd like me to say in this introduction, Dr. Miles replied that he had a blessed career and that he is a passionate gardener with three gardens of his own. He even serves as a Minnesota Ask a Master Gardener Expert online. I assume he provides that expert advice on a pro bono basis, but I did not ask. Without further ado, I offer my sincerest thanks and my heartiest welcome to Master Gardener and humanitarian, Dr. Steven Miles. Wow, thank you. So giving up your Celtics tickets didn't really temper you at all. That's pretty generous. Thank you. I got into this looking at the behavior of US doctors in the war on terror. And what I expected to find was what I was looking for after the pictures of Abu Ghraib prison came out was how the military suppressed what the doctors' protests were to what was going on at Abu Ghraib. And after looking at about 70,000 pages of declassified documents, I found to my horror that in fact the physicians had been built in without protest into the brutal interrogation system. And so the book at that point changed and I wrote a book called Oath Betrayed about how those doctors became part of the infrastructure of torture. After that, what I did was I began to work on the question of accountability for physicians both with regard to the United States and then with regard to the world. Now, of course, everybody as soon as you say that says, well, this means, you're talking about Dr. Mangala and the Nazi doctors trial at half 1946. This was where a psychiatrist coined the term medical war crimes because what they found in the concentration camps was a series of experiments that were basically conducted by using time to death as a indicator for the success of the experiment. For example, how long would it take a person to freeze to death in given types of wetsuits, pilots or submariners or battleship crew was shown down there in the lower left. And so they keep tinkering with the suit to find out how long if they could extend the time to death. How long would it take somebody to suffocate in conditions of rapid decompression for the Nazi program to develop high altitude aircraft? And they had 23 defendants because that's how many people were held in the defendants box, seven were hung and I'm more imprisoned, seven were acquitted, but more importantly, 1600 Nazi medical scientists were brought to the United States to work on Cold War research on biological chemical warfare and aerospace military equipment. Steve, could I just interrupt you for a second? I'm not sure you're sharing your slides. I'm not, hey, are they sharing now? Yeah, now we're seeing the, yep, they're perfect, you got it. Got it, okay. Thank you. You're welcome. All right, so this is what happened as you can see down there in the lower right, that's the experiment with cold suits to protect people from freezing to death. And then the other one is a decompression suit. Torture is a term that has a very specific definition. It's not the same thing as some psychopath who locks somebody in a basement in Philadelphia and then tortures them for a long period of time. Torture refers to the infliction of severe pain or suffering that's intentional, but more importantly, torture in international law says that the infliction of severe pain or suffering is done by a person acting in an official capacity. That is, torture is an act of government against usually a prisoner. Now, after the Nuremberg trial, there were a whole bunch of things that happened. First, a Congress of the World Medical Association, that was, for example, the American Medical Association, the British Medical Association, French Medical Association, South African Medical Association formed in Paris and they passed a law saying that doctors should not violate international law. And they went on to clarify that in various iterations until 1975 with the Declaration of Tokyo that specifically says that doctors should not directly or indirectly participate, help conceal, loan any premises or equipment for, or allow the use of medical facilities for torture. In 1997, after some physicians who were in the Rwanda slaughter fled and picked up licenses in Europe, the WMA said that there should be no license for a doctor who's fleeing prosecution from war crimes. The Britain has allowed two to stay. And then after the United States, where the physicians were quiet on the medical torture and torture of inmates during the war on terror, the WMA said that there was a duty of doctors to denounce and document, even if they had to go to underground connections to human rights bodies. The United Nations essentially adopted the various positions of the World Medical Association as time went by. Now, at the present time, more than 100 countries, probably about 150 countries use doctors for torture. And doctors have several key roles in torture. The first is that what they do is they devise techniques to minimize scars. This is so-called stealth torture because the scars are evidence of torture and the regime doesn't wanna do that. And so this sets up a warfare between pathologists who are working for human rights groups and torturers. For example, for a long time, the torturing regimes we're using and still are using electric shock, but a good pathologist can spot little calcium deposits under the skin where the electrodes go through where the shock is applied. The second thing that they do is they keep alive those who are supposed to live. Some people are not intended to die under torture. People who are being waterboarded, for example, that's a technique that does not leave scars. And then the third thing that doctors do is they conceal torture. For example, by writing false death certificates that say that somebody had a heart attack or died of a hunger strike or something like that. And then the torture disappears. Now, I'm gonna just show you some data from 1972 on where I attempted to chase down this issue. And I was looking for actions by international or national courts or medical licensing boards. And I didn't include acquittals. And I'll tell you, this is easily the most arduous literature search I've ever done. I set up a Google search in multiple languages using the word torture and doctor. And this is a Spanish language search from Argentina. And so then what I did was if you hit the translate this page, then what you get is this story which tells about Dr. Bianco serving at the military hospital at the Campo de Mayo. He was sentenced to jail in 2000 years for the kidnapping of two children. And what happened here was that he took birth certificates while they took women who were gonna be murdered and then they were pregnant in prison and Argentina having laws against abortion waited till they could be delivered by C-section or natural delivery. And then this physician, Bianco, wrote a false birth certificate saying that the parents were guards or soldiers in the prison. And so those kids would be raised as military offspring and their natural family would never know that the kid was even born until finally the grandmothers of the women started searching for them and DNA potentially found the true story on several of them. And so that first search, which ended 2010, I found this, which is an interesting pattern if you're into dots. What it found was that medical boards took most of the actions, okay? For example, you see those dots, black dots, and that courts as squares took fewer actions except in Argentina where the medical associations really stayed out of it. And then there were three in South Africa. And then you notice those large circles are international courts. Now, international courts like in Yugoslavia don't play much of a role because they don't dig down to the lower ranks of torturers. They have such limited capacity that they mainly only take on political leaders who happen to be physicians. After Nuremberg in 1947, the first case was 1975, that is it took actually 30 years for one doctor to be found guilty of participation in torture. All of the doctors from 1947 to 75 had complete immunity. And this guy was picked up and nobody paid attention to the fact that he was a physician until a paper was written pointing that out in about 1990. He was called the orange juice doctor because every time he saw a tortured prisoner he'd give them some orange juice and say he'd be back later to give them more treatment. He went to jail, I tracked him down, he's practicing ophthalmology in a suburb of Athens. I don't pay any attention to the physicians who are political leaders who run torturing regimes. I'm just not interested them. I'm more interested in clinicians. There are a bunch of these. So who are these people? The first question people wanna know is why do they do this? Are they psychopaths or what? And actually what they are is basically careerists. But they're certain kind of careerists. They're highly patriotic. They're on the right wing of the political spectrum. And they accept the argument that there's a national emergency. I'll come to the last criteria in a minute. This is Dr. Lobo. Lobo of course means wolf. He's a Portuguese doc or a Brazilian doc and he wrote a book called The Wolf and the Sheep in which he described his career as a torturer and he said, man has used torture and assassination for thousands of years and permitted it as long as it's socially organized. It's just a moment from the inquisition to the murder of the Jews by the Nazis. This is human nature. I'm not ashamed to be part of it. And part of his argument was that no court has a right to try somebody simply for human nature. These doctors also get groomed into the process. First off, they're recruited for very high salaries and very high ranks. Salaries that are higher than they can earn in ordinary medical work either in the military or in the private sector. They're given orders, they do not, they do not experience fear that if they don't torture, they will be tortured. I only found three cases of that. Four cases, two in Iraq and two in Nazi Germany. The regimes don't wanna alienate their medical professions by creating a climate of fear because most of these countries don't have very many doctors. And if the doctors emigrate they even create a bigger national shortage. These docs are not crazy people. Although some of them go crazy in the prison environment. Governments keep in mind that a torture doctor is needed by the government as I talked about earlier. And so there's a contract between the torture doctors and the governments that say you will be an armist. We won't let it be known you're doing this work and we'll protect you if anybody comes after you. So they pass amnesties. They require military courts to screen cases. They block access to records. They specifically exempt military MDs from licensing punishments, sometimes to the extent of setting up a military medical association so that the doc is in no way accountable to a civilian medical society. And even if the license is stripped, they just keep the doc in military service and let them work in military or based hospitals. As I said earlier, what you see here is a shift. You see initially around three fourths of the cases were medical associations. But when you look at the same time you start seeing that the courts seem to be playing a larger and larger role. That is the Medical Associations Act first. And courts and medical associations or medical licensing boards have much different roles generally. A court prosecutes crimes, okay? Murder, false death certificates, kidnapping. And they can imprison people or impose monetary fines. In some cases they can revoke pensions, especially court marshals. Medical licensing boards have a difficult problem because they don't prosecute crimes. What they do is they prosecute unprofessional conduct. For example, there may not be a law against a doctor having sex with a patient, but many licensing boards will punish that as unprofessional conduct. And their sanctions are entirely limited to either censure or to suspending or revoking the medical license. They do not have the power of imprisonment. The civil society actually has played a huge role, a larger role than either courts or medical associations in punishing these docs. And this is an example of a denounce. These civil society or human rights groups, what they'll do is they'll take pictures of the victims and then they will plaster them all over the clinic and at the doctor's home. They'll write the indictments on the street and then they'll set up a website that gives the doc's home address, his phone number, his office address and phone number. And then those websites will have lists of all the people they tortured with biographies and pictures of them. And basically they try and shame the people out of work. The response to neighborhoods which deal with those kinds of demonstrations in the neighborhood is to demand that the physician move out of their neighborhood to someplace else. And that has been in effect in several cases. Now, what I wanna show you here is the history of how sanctions develop. It's no secret that doctors generally are conservative politically. That is they have a political affinity with regimes even when the regime is a torturing regime. And of course the courts are part of a torturing regime. And the important thing to know about torture is that torture is not aimed at the person who robs a gas station, for example. Torture is aimed at potential political opponents. That's why it's aimed at people who are journalists, people who are intellectuals, heads of political parties, student leaders, union leaders and so forth. That's why Saudi Arabia had that journalist sawn apart by a doctor and an embassy in Turkey about a year ago. And so what happens is under the torturing regime, the medical association quietly ignores and goes along with the program of torture. The next thing that happens is that civil society builds increasing resistance to the torturing regime and starts compiling evidence about how doctors are involved in torture. And meanwhile, the government is aggressively acting to set up amnesties and pardons and destroy evidence and run death squads against civil society who is part of that resistance. The next part is that the civil society is able to awaken the medical association students by saying, look, what is this business about? Do no harm. What's this business about the Hippocratic Oath? And eventually the medical associations also are adversely affected by the climate of torture. And so they side with civil society and they begin to apply sanctions against torturing doctors. At that point, the government then develops a new set of policies which are designed to protect doctors. And then the final stage is that the courts begin punishing tortures and that's why the courts follow the medical associations rather than the other way around. This is more current data running up to 2015. I would make this longer except it's just too hard to build this kind of a graph. And what you can see is that both the number of nations, the light gray and the number of cases is steadily increasing. However, the rate of increase dropped markedly after the United States failed to do anything about the torture doctors in the war on terror. Nevertheless, these cases are really a tiny part of the involved doctors. For example, Argentina, they had more than 200 doctors who had been identified as torturers. They only punished 12 in the Sao Paulo process and 12 in the province of Brazil. They had 110 allegations, only 22 were punished. There were no allegations or punishments in any of the other provinces of Brazil, including much larger ones. Chile, again, only 10 sanctions of 80 really solid allegations. And so it's possible to categorize nations themselves as to various stages of how they look at physician tortures. For example, you have countries like North Korea. Now, if I was giving this lecture in North Korea, the soldiers would be in the house right now and I'd be dragged off and you wouldn't get to see the last 10 minutes of this discussion. And that would be an immense loss for you. That is, there's no discussion of physician complicity with torture. Stage two are countries that condemn physicians' tortures in principle, but have not sanctioned one. They've never punished one. The US, Philippines, Venezuela, a huge number of countries fit into this category. Stage three are the ones that have done a symbolic act against one or two physicians. Egypt has done one. The UK has done one. Sri Lanka has done two. Turkey's done one. South Africa did two, so forth. And then you have the assist countries that have set up partial systems for punishing doctors for assisting torture. Argentina, Brazil, Chile, or Rwanda and Uruguay. Now, interestingly, Rwanda is the country that has punished more of its physicians, the greatest percentage of its physician supply for torture than any other country in the world. This graph I did a long time ago. I think this is 2010 data, but it gives you a verbal picture. The green ones have systems for punishing torture. You can see they're mainly in South America, which is an interesting phenomenon. And there's Rwanda and Italy. The red countries are countries at the time which I could determine had physicians who tortured. And the gray ones had punished torture numbers, token numbers. And then the white ones, I didn't have any data on. I filled in all those white ones now are red. And the green and gray ones did not change. On a more optimistic site, it's important to note that the physicians are essential to the resistance to torture too. First off, we have special skills for detecting torture. We have a special autopsy protocol called the Istanbul Protocol that's designed to look for torture related injuries. For example, ordinary autopsies, they look at vital organs. But for example, if a person is hung by having their arms behind their back and then lifted up by a rope behind their back, there's a twisting tear in the shoulders that occurs, which will not be detected by a conventional autopsy but will be detected by the Istanbul Protocol. We have codes against torture and we have a special network of things called medical associations which could censure doctors who torture and we have licensing boards. But I think our strongest asset is that we have an international community that even medical communities in torturing societies have ways of contacting human rights advocates during and the course of professional meetings and so forth to serve as a monitoring function. And in fact, that set of relationships which is rich and unexplored is the primary means by which the kinds of cases that I was digging out were found. My list is really a minuscule set of cases of physician complicity and also it's got an important bias in it because the more closed the society is, the harder it is to document cases of medical complicity with torture. For example, it's relatively easy to find the many cases of medical complicity with torture in Spain. It's almost impossible to get information out of North Korea. And so there's an overfinding bias that relates to the nature of getting information out of a country. I got to actually go after one guy. We had a good time. The court let Wooder Bassoon off of 200 count criminal indictment and he was the guy who designed the chemical and biological weapons programs and also some special ops against individuals in the African National Congress. And finally, the medical board took him up. I got called down to testify. In the pre-COVID time, we actually dressed up when we worked professionally. And I actually got the board to condemn him for unprofessional conduct. And this case has now been going on for eight years and still has progress. We're working through a kink in the sanctions process. Let me see if I can put you all up and then we'll... There we go. Hi. Okay. First of all, Dr. Miles, thank you so much for the presentation. You mentioned in the book the fact that you can have doctors who torture and might do absolutely heinous things in the course of their daily work and then go home and be perfectly decent family members and otherwise apparently good members of society. Can you just talk a little bit about that split in people that allows them on the one hand to do horrible things in the course of their profession and then otherwise seem like quote unquote normal people? Yeah. I mean, there's actually a research literature on this that is pretty bad. It's really low quality research and some of it uses university students who go into a place and they'll like the, you know, those experiments where they take and turn them into tortures and stuff, but you know, a university student going to Yale who's recruited of a study in the Milgram thing where they torture people is nothing like anybody who is inside a prison where people are visibly taken apart. Okay. So the studies just aren't the same. The torture institution, I think the best description of what it is is basically a total institution and in the sense of a sociologist called Irving Goffman and it also is as a total institution, its ethics is enclosed, but the other thing that's so interesting about it is that as a microcosm, it becomes a microcosm of the political ideology at the time. And that political ideology defines the people inside the prison, the prisoners, as other who don't have customary rights, Jews, Islam, old fascists, take your pick. Okay. And so communist, I mean, you can name anything you want. And once you define people as an other that way, then you can define their legal rights as being non-existent, but then when you put them in a special institution and then you remove the accountability, then you've created an environment within which torture can happen. Now, the other thing that's fascinating about these environments is that there are, these oral traditions start, a good example is the ticking time bomb argument that if you torture somebody, you can get information. There's a huge body of research showing that you can't do that. The only people you torture and get information out of our graduate students writing a PhD, okay? And for other people, if you torture them, what happens is they stop telling you the truth, okay? You lose your ability to recruit them as human intelligence, okay? And the other thing that's been fascinatingly found is you cause them to shift from being a political opponent to being a viewing, detorturing regime as transcendently evil. And once that happens psychically, things like suicide bombers happen and also the accommodation, potential political negotiation between the two sides becomes impossible because at that point it's a war of good versus evil. You have another thing happen is that the tortured person starts spilling stuff which finally a tortureer will accept. And at that point, bad policy follows from that spilled information. For example, we took a guy in Afghanistan, we tortured him in Cairo. He said that Saddam Hussein and Al Qaeda were working together on biological weapons and that become part of the pretext of the war and around. He never would have said that if we hadn't tortured him. He said it just to try and get himself not tortured. And so the enormous costs of that bad intelligence actually paid forward. Ticking time bomb is not a description of how intelligence works. Yeah, and to my knowledge, there's never been a scenario where that actually was the case where the time bomb. In fact, the Israeli Supreme Court asked Mossad to supply an example of the ticking time bomb to pursue this idea of torture warrants and said, you can clean it, the clean strip all the side data off you need to preserve the confidentiality case. We just wanna see this situation. And Mossad was not able to come up with one case for the Israeli Supreme Court on the ticking time bomb scenario. We have a question from Lachlan Faro. Your book about the dark sides of humanity, not just doctors is an invaluable compliment to the April 2020 author session we have with Nicholas Christakis about his book, Blueprint, The Evolutionary Origins of a Good Society, which stresses the aspects of human nature that Nick is convinced provide a solid basis for hope for the future. Can you offer some comments about we can integrate both perspectives, our capabilities for good and our capacities for apathy or even true evil as we try to build a better future? Yeah, well, I think Nick is a big guy on social contagion and social contagion is real, okay? And he's applied it to a number of dynamics and it's quite clear, for example, that social contagion, that is the infiltration of ideas within the American culture during the war on terror, including that show on Jack Bauer, what was it called? 24. Yeah, 24. I mean, this concept of social contagion of these kinds of standard ideas winds up actually creating a torture prone climate. Now, the other way of looking at this is in, say the book, The Better Natures of Ourselves by Pinker. And what he talks about is the social contagion of the concept of empathy. And through a variety of means as a way to show that things are getting better. And in fact, things are getting better. If you take, for example, that book, Breaking the Chains, we have to remember that only 100 years ago, something like 50, 60% of the world's population was in debt, peonage or slavery. They're not anymore. Torture basically is, slavery is rare, but still exists. Torture is actually becoming less common at an epidemiologic scale. Largely have gotten rid of amputations, the penal amputations, they're down, stoning is almost gone, executions are going. This and transparency is turning out to be a huge deal. The social media has proved invaluable in spreading accounts of torture that is actually toppling governments. And there was a huge discussion of giving the web to Cuba today in the New York Times, it was just fascinating. Hi, Laughlin. Christine Mitchell asks a question. She says, thank you, Steve, for all your work on this. It must be disheartening. Why do you think there is so little other work on this topic in bioethics? It has always surprised me that bioethicists are loath to call some things like this clearly wrong. There is a habit of mind among ethicists that presents as neutrality, often appropriate, but in cases like this, not so. Surely we can tell the difference. Do you have advice about how to teach bioethics students about when neutrality and when condemnation are warranted? Oh yeah, that's a good question. I mean, I'm impressed with how bad bioethics has been. I mean, after Oat B. Trade came out, they invited me out to give a plenary session at ASBH and I got there and they turned it into a panel discussion with pro and con physicians should be involved in torture. And there were two physicians there taking the pro position, two of us taking the anti-position which is just morally irresponsible considering the state of international law. I also got a review in one bioethics journal by a philosopher who believes that torture by physicians can be justified. This is a alienation from society that is unsuited to the profession of bioethics, that we do not have a duty to do transgressive bioethics to take positions where the moral consensus is solidly on the opposing side. Furthermore, we have people in our ethics community who are endangered by their torturing society. Our ethicists, for example, in Turkey are grave danger and some of them are very close friends of mine. So I think that though the important thing to teach medical students is not about torture but rather to teach them about a spine and that they need one. And indeed we've seen that played out over the last four years in spades but you have students, for example, have to understand that going along with the drug company suppressing bad results on research, going along with an HMO that is denying a beneficial therapy because of its costs, okay? That these instances, these institutions ultimately are gravely damaged by the lack of spine in the people who work in them. And the research scandal at the University of Minnesota is a good example. Somebody should have said no. Somebody should have said no as loud as it took to stop that experiment. And HMOs have been gravely damaged by students without spine. And so we talk about the heart and mind of medical students we should be teaching about the spine of medical students. And among those, I think the biggest error in medical school education is this concept of dual loyalty. There are no dual loyalty ethics. There's a dual loyalty problem. But a physician has a very clear duty to the beneficence towards their patients with the sole exception being some instances like psychiatric care and public health care with regard to the well-worked outward ethics of quarantine and so forth. But you don't have a situation where a physician has a duty to a military and to a patient for the purpose of paying an appointment patient. Could I just follow up on that for a second? Just I'm hearing your point about dual loyalty, but is it possible that clinicians of any sort, doctors or nurses, take on the mantle of that morality when they are in that role, but we don't hold them to that in other situations. I mean, if you've gone to medical school and you have an MD or a nursing school in RN, are you bound to a code of morality 24-7? Or can you think like the psychologist did at Guantanamo, that they were not doing clinical practice and therefore it was a different role that they were playing? It's important to recognize that the code of ethics that said that the psychologist was working for the interrogation system and not the military was constructed by a panel that was three-fourths taken over by the military intelligence community inside the APA. And the APA allowed that document to be constructed by the military and then disseminated to members specifically to grant cover to the psychologist at Guantanamo. Furthermore, the construction of that document as it was being constructed specifically said during the process, there would be no consideration of international law as it applied to Guantanamo. And secondly, there would be no discussion of research relating to the inefficacy of course of interrogation. And so the document was intellectually flawed. It was morally flawed and it was flawed in the sense that it was not grounded within an intent with regard to beneficence, but rather to with regard to the utilitarian purpose of a misguided and intellectually bankrupt interrogation system. Do you wanna know how I really feel about it? Let's see, who else we got here? The WMA, good question. I wish I knew, I partly wrote the book to kind of jab them when they're sick to get them to come out of the closet and talk about it. What happened with the WMA? See, Germany was, right after the war, Germany was critical to the formation of the WMA because which had US, France, Britain. And the Cold War was crystallizing right away and they wanted to grab West Germany for the WMA. Well, the problem was that because so many of the German docs have been members of the Nazi party, the German Medical Association wanted to say there would be a collective responsibility, not a personal responsibility for these human rights abuses. And in fact, the original position of the WMA at its first meeting was personal responsibility. But then in order to get Germany to join, they had to agree to collective responsibility which meant no responsibility. And that's been their position ever since. Torture is not, Charles, when it's torture is not legal anywhere, it's illegal under international law. And there are at least eight major international laws that apply to torture. And there's also, so it's just not legal. Although there are a number of situations that people call torture that do not meet the definition. And then another question pertains to the Hippocratic oath. How much, Dr. Miles, do you think oaths like that or other ones that people might take or even the rules within any state board of medicine to remain licensed? How important are those kinds of things as opposed to say the local culture that one is practicing in, the context that one was taught in and what he or she saw from their teachers when they were coming of age? In terms of the moral compass that I said that I referred to when I was introducing you. Well, I believe there is an internal ethic of medicine. And that's been well-established. That has been articulated since the beginning and it did start with the Hippocratic school and was a sharp innovation from the Egyptian and Arab schools to proceed it. The problem is the Hippocratic oath is not well understood. You can understand it by reading this book, Hippocratic Oath and the Ethics of Medicine, which I did the whole thing out. The last decent interpretation was France in the 19th century. But I think it exists. The question is who's going to inculcate it in the profession? And also you have this problem of, for example, oh, sexism with regard to who the interpreters are of the internal ethic of medicine. For example, the abortion clause in the Hippocratic Oath is not about abortion. It was about something entirely different. And there's a fascinating carve out for reproductive healthcare in the international treaties pertaining to human rights. So I think that the question comes about making medical ethics closer to the human rights movement rather than a standalone argument. I don't feel that Emmanuel Cot is a generalized internal or international approach for medical ethics. Another question. Some journalists have recently posited a direct link between the enhanced interrogation methods of Mitchell and Jessen right back to the MK Ultra Research of Evan Cameron. Yes. In Montreal. If true, does that make it one wonder if the US has maintained a standing capacity and lab for torture within the CIA? Do you have an opinion? I don't believe they have such a lab, although I did write a paper about the research designs at Guantanamo, which were based on the work of Charles Murray. And there was a specific randomized trial at Guantanamo involving rotating attitudes and information and coercion in three rotating combinations in order to try and then seeing what the output was. And this was a log of one experiments largely got out and it's pretty fascinating. And that is in the second edition of both betrayed, I put that literature in. And the dog, Vicki, you wanna know where the dog is? The dog is Lynn. She's a rescue shih tzu. She is adorable. She's really smart. And L.I.M, she's named for the founder of the women's suffrage movement in China in the 19th century, a journalist and writer who finally hit the glass ceiling, grabbed her husband's money, ran away to Thailand and established a business cartel and became very ruthless. You asked. Go ahead. Some of the intense. Yeah, let's even talk about Dan Sophie. Oh yeah. The question it has to do about psychological torture and physical torture. This actually has been studied by a terrific researcher and he's a servant researcher. Metin Bozeglu. And what he found was that the incidents of PTSD after psychological torture as opposed to physical torture was exactly the same. And psychological torture consists everything from neglect, degradation, things like sham executions and prolonged sleep deprivation, bright lights, loud sounds, playing absolutely pernicious pop music at loud volumes for extended periods of time. And, but it has exactly the same amount of PTSD. It has of course fewer of the specific physical sequelae of physical torture, but it can be lifelong disabling. But Dr. Maz, I wanna bring your attention to one of the last questions. What should the, and I have very strong opinions about this myself, but I'd love to hear your thoughts. What should the role of doctors who do not participate in torture but are aware of the role that doctors have played in torture be in ending this problem? What's the role of doctors in general who aren't participating in torture? Well, in India, for example, more than 50% of physicians have seen a tortured person. In a profound way, a physician is a human rights advocate because human rights advocacy is a form of beneficence. And that means that physicians have an obligation, not simply to the clinical wellbeing of a particular torture victim, but an obligation vis-a-vis the infrastructure or torture itself. That infrastructure includes the parts of the sociopolitical system that cause torture, as in the case of the upgrade thing, but it also includes the infrastructure of impunity, which is the failure, for example, of medical associations and criminal courts to take on these cases. This requires a tenacious participation in gathering data and in reporting and in insisting that national medical associations produce templates for holding docs accountable and then seeing that they do. And I suggest a bunch of these in the last part of the book. Along those lines, I saw there's a statistic that says, well over half of the people in the United States who are themselves being trafficked, see physicians within the year, within any given year. And so one of my feelings and thoughts is we need to keep focus on these kinds of human rights violations and issues so that we can all keep pressing for what's good and what's right. We don't teach how to recognize these people. You know, ultimately, torture survivors in the United States have roughly the same prevalence as people with Parkinson's disease. Every one of us in medical school and in practice sees people with Parkinson's disease and every medical school curriculum and board test says this is how you recognize it and we don't do that for torture. It's totally invisible. Harvard has a good center of course but the screening and the recognition of torture survivors as for domestic violence not people who are in situations of domestic violence or being trafficked or what have you is very, very low. And if we spent more energy on that than on lowering blood cholesterol we would have better public health outcomes. I fully agree and maybe this will be the last question. What are the one to three things that you hope people attending this session will think or do differently as a result of your great work? What will make the greatest difference? Well, I think everybody has to ask themselves how are they gonna solve the backbone problem? The second question I think the really important question is to learn how to recognize torture in their own clinical practice. There are higher risk people than other. For example, if you look at countries in East Africa approximately 20 to 30% of the population has been tortured there but of the people who come here around 50% have been tortured because tortured people are disproportionately likely to leave. And to say that you haven't seen a tortured person is simply to admit your own distancing from people. So number two or three I think we have to ask the question of how is medical ethics going to move without abandoning respect for autonomy move closer to social justice? I want to thank you from the bottom of my heart for being here this evening and giving us this wonderful presentation and thank you so much for all of the work you've done for decades and showing us what it means to have a real backbone. Thank you for your example.