Reis C, Ahmed AT, Amowitz LL, Kushner AL, Elahi M, Iacopino V. Physician Participation in Human Rights Abuses in Southern Iraq. JAMA. 2004;291(12):1480-1486. doi:10.1001/jama.291.12.1480
Author Affiliations: Physicians for Human Rights, Boston, Mass; School of Public Health, University of California, Berkeley (Dr Ahmed); Survivors International, San Francisco, Calif (Dr Ahmed); Divisions of Women's Health and General Internal Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (Dr Amowitz); and Trinity College, Hartford, Conn (Ms Elahi).
Context Physicians are known to have participated in human rights abuses in
Iraq during Saddam Hussein's Baathist regime, but the nature and extent of
that participation are not well documented.
Objectives To characterize the nature of physician participation in human rights
abuses, identify structural factors that facilitated physician participation,
and assess approaches for accountability and for prevention of future physician
participation in abuses.
Design, Setting, and Participants A self-administered survey in June and July, 2003, of a convenience
sample of 98 physicians and semistructured interviews of hospital directors
and physicians in 3 major hospitals with general surgical units in 2 cities
in southern Iraq.
Main Outcome Measure Respondent reports of peer and self-participation in human rights abuses
in Iraq since 1988.
Results The majority of participants were male (88% [86/98]) and Shi'a Muslims
(97% [95/98]). Respondents reported a mean of 6.8 years in practice. A total
of 71% of respondents (65/91) reported that torture was a problem to an extreme
extent in Iraq since 1988. The proportion of respondents indicating that,
since 1988, their physician peers as a group were extremely or quite a bit
involved in human rights abuses included 50% (42/83) for nontherapeutic amputation
of ears as a form of punishment, 49% (39/79) for falsification of medical-legal
reports of torture, and 32% (25/78) for falsification of death certificates.
Fewer numbers of respondents (range, n = 2 to 6) reported participation in
abuses themselves. More than half (52% [48/92]) indicated that physicians
did not willingly participate in these abuses; 93% (52/71) reported that the
Iraqi paramilitary force Fedayeen Saddam was responsible for initiating physician
complicity. Fear of harm to oneself or family members was a common explanation
for complicity. Respondents reported that physicians who refused to participate
in abuses faced consequences including loss of job, imprisonment, torture,
and disappearance. Respondents reported on preventive measures that should
be undertaken to prevent physician involvement in future abuses, including
increasing human rights and ethics education of physicians (99% [79/80]),
legal provisions to ensure effective monitoring (97% [73/75]), punitive sanctions
for physicians who commit abuses (96% [77/80]), and ensuring the independence
of physicians from state authorities (95% [76/80]).
Conclusions Although not generalizable beyond the study participants, the findings
of this study suggest that among those surveyed, physician participation in
human rights abuses included falsification of medical-legal reports of alleged
torture, physical mutilation as a form of punishment, and falsification of
death certificates. As Iraq rebuilds, it is essential that the country address
these violations and enact measures to prevent physicians from future complicity
in human rights abuses.
During the 1979-2003 Saddam Hussein regime in Iraq, violations of human
rights have been reported to be widespread and systematic.1 These
reports are supported by the findings of a study of the prevalence of human
rights abuses in 3 cities in southern Iraq, reported elsewhere in this issue
of THE JOURNAL.2 In that study, 47% of households
surveyed reported human rights abuses occurring among household members since
1991. Although the participation of physicians in human rights abuses in Iraq
during the Baath regime has been documented,3- 7 Iraqi
physicians have not, to our knowledge, been surveyed about their own experiences
and views on physician involvement.
A prerequisite of the successful reconstruction of Iraq is the identification
and addressing of past problems to prevent their recurrence. Accordingly,
Physicians for Human Rights (PHR) conducted a self-administered survey of
physicians in 2 cities in southern Iraq to assess patterns and practices of
physician participation in human rights abuses, to identify structural factors
that facilitated physician participation in human rights abuses, and to assess
physician attitudes about human rights abuses and measures to prevent physician
The survey was conducted during a 2-week period in June and July 2003
in 2 major cities in southern Iraq: An Najaf city in An Najaf governorate
(population 931 600) and Nasyriyah city in Dhi Qar governorate (population
1 454 200).8 Civilian hospitals were
selected on the basis of having surgical capacity because many of the alleged
abuses involved surgical procedures and because hospital administrators and
other key informants indicated that evaluations of detainees were most often
conducted in these facilities. Eligible participants were physicians and surgeons
practicing in these hospitals at the time of the survey. Physicians practicing
exclusively in outpatient clinics, maternal or pediatric hospitals, and rural
hospitals who were unlikely to have been faced with opportunities or forced
to participate in abuses were excluded, as were medical students and residents.
All surveys were hand-distributed by a PHR researcher and/or the hospital
director or the director's representative to physicians working at each of
the 3 hospitals in the 2 cities based on the director's verbal indication
of the number of physicians and surgeons practicing at the facility. All questionnaires
were self-administered, and physicians returned completed surveys either to
the office of the hospital director or to the PHR researcher. Reasons for
not responding to the survey were not available because the survey was self-administered
and conducted anonymously.
The 31-question survey (available on request from the authors) included
questions on respondent demographics, medical training and practice, and experience
and knowledge of physician participation in human rights abuses since 1988,
a date cited by physicians as the start of a government campaign to involve
physicians in human rights abuses. Human rights abuses were listed in the
survey and torture was described as "torture and ill treatment" as defined
by the United Nations Convention Against Torture.9 Respondents
were asked both about their own involvement in abuses and about involvement
by peers. Other survey domains included consequences of physician refusal
to participate in abuses, knowledge of and attitudes toward medical ethics,
and recommendations for reform. Several items were adapted from previously
field-tested PHR surveys of physician participation in human rights abuses
in Turkey10 and Mexico.11 Questions
regarding torture were based on the definition of torture in the United Nations
Convention Against Torture9 and on key informant
and other reports of abuses in Iraq. Questions regarding restriction of work
or educational opportunities and abuse experiences used dichotomous "yes"
or "no" responses. All other questions used Likert-type scales for responses.
The questionnaire was written in English and translated into Arabic.
Eight regional, human rights, and medical experts reviewed the questionnaire
for content validity. The survey was pilot tested by 4 Iraqi physicians and
suggestions regarding clarity and cultural appropriateness were incorporated.
In addition, semistructured interviews were conducted with 3 hospital
directors and more than 60 physicians in the 3 civilian hospitals. Due to
the sensitive nature of the information sought in these interviews, physicians
were recruited by chain or snowball sampling12 using
hospital directors as initial key informants. Interviews were conducted in
English or in Arabic, with the use of a translator, based on participant preference.
Detailed notes were taken of all interviews.
The survey and sampling strategy were based on prior studies of physician
participation in human rights abuses.10,11 The
research was conducted in accord with the Declaration of Helsinki.13 All data were kept anonymous. A cover letter attached
to the survey instrument described PHR and the purpose and subject matter
of the survey. This letter stated that participation was voluntary and anonymous,
that no individual's information would be reported in an identifiable way,
and that no compensation would be given to individual participants. This information
also was provided to all physicians who agreed to be interviewed. A small
donation was made after the surveys were conducted to hospitals where respondents
practiced in recognition of their time and as an incentive to increase participation.
The data were analyzed using STATA 7.0.14 Analysis
consisted of descriptive analysis of means and proportions only.
According to the 3 facility directors, the physicians practicing in
the surveyed facilities included 105 of 195 physicians practicing in An Najaf
and 56 of 113 physicians practicing in Dhi Qar governorates. No written records
were available. Of the 116 completed surveys from physicians and surgeons
returned to PHR, 98 were eligible. The remaining 18 were not eligible because
they were completed by residents or medical students.
Of the 98 physician respondents, 88% (n = 86) were male. Ninety-seven
percent of respondents (n = 95) identified themselves as Shi'a Muslim, a percentage
consistent with the ethnic composition of the area where interviews were conducted.2 Respondents reported a mean (SD) of 6.8 (6.9) years
in practice, and most (81%) were specialists. When asked which best describes
their practice experiences between 1988 to the present, 62% indicated practicing
in a civilian institution and 35% in a military setting.
Seventy-one percent (65/91) of respondents reported that torture was
a problem to an extreme extent in Iraq since 1988. Sixty-five percent (56/86)
stated that ethnicity/religious affiliation was extremely important as a factor
in whether a person experienced torture or ill treatment since 1988.
A majority of respondents (73% [52/71]) reported that the Fedayeen Saddam,15 a paramilitary force that reported directly to Uday
Hussein, was responsible for initiating abuses in which physicians participated.
Other Baath regime–affiliated groups16 identified
as initiating abuses included other Iraqi paramilitary forces (39%), the Republican
Guard (34%), and the police (34%). When asked to what extent physicians participated
willingly in abuses, 52% (48/92) of respondents stated that physicians did
not participate willingly at all. Fifty-one percent (44/87) indicated that
physicians who did not comply with abuses lost their job. Other commonly cited
consequences of refusing to participate in abuses included imprisonment, torture,
disappearance, and being forced to flee (Table 1).
When asked about the frequency with which Iraqi physicians in general
were forced to be involved in abuses since 1988, respondents indicated that
they understood that physicians were "extremely" or "quite a bit" involved
in a variety of abuses, including nontherapeutic ear amputations (50% [42/83]),
falsification of medical-legal reports of torture (49% [39/79]), falsification
of death certificates (32% [25/78]), release of medical records to state officials
without patient's consent (32% [22/67]), removal of a (dead or alive) patient's
organs without the patient's consent (17% [12/73]), participation in torture
(8% [6/73]), and administration of "mercy" bullets to kill survivors of torture
or ill treatment (4% [3/75]) (Table 2).
Fewer physician respondents reported participating in these abuses themselves,
with responses indicating such participation ranging from 2% to 7% (Table 3).
Ninety percent of respondents stated that there is a code of ethics
for Iraqi physicians published by the Iraqi Medical Association. Respondents
indicated that the code includes specific obligations for physicians to honor
a wide range of basic human rights (Table
4). Two thirds (66%) of respondents stated that according to the
code, even when threatened the physician may not use his/her knowledge in
a way that is contrary to respect for human life.
Seventy percent of respondents reported receiving some training in medical
ethics and 56% indicated that their training in ethics has been useful. Ninety
percent of respondents thought physicians should receive formal training in
ethics. When asked about the ability of physicians in Iraq to abide by their
ethical duties since 1988, 39% reported that physicians were able to do so
poorly or not at all. Seventy-nine percent agreed that it is extremely important
to improve medical ethics and respect for human rights in the health sector,
and 95% reported being extremely interested in learning more about medical
ethics and human rights (Table 4).
According to Iraqi physicians contacted after the survey, the Iraqi
medical code of professional ethics included provisions on physician respect
for patients, confidentiality of patient information, physicians' duty to
treat their patients to the best of their ability, and their duty not to harm
patients intentionally. These physicians indicated that these are recited
as an oath by graduating medical students.
Of 85 respondents, the majority (93%) thought that physicians who participated
in human rights abuses should be punished or reprimanded; 7% stated that physicians
who participated in such abuses should not receive any sanctions (Table 5). A total of 99% (79/80) of respondents
indicated that increased human rights and ethics education of physicians should
be implemented to prevent physician involvement in future abuses. Other measures
that were supported are listed in Table
Most of the physicians interviewed reported that physician participation
in human rights abuses was common under the past regime. According to them,
the government took deliberate steps to create a culture of fear and mistrust.
The government "wanted the physicians' faces to be visible . . . [They] wanted
the patients to take revenge on the physicians," reported one surgeon.
Among the structural factors that contributed to physician participation
in human rights abuses in Iraq, interviewed physicians cited physicians' fear
of harm to themselves and their families if they refused to participate in
abuses. Physicians who refused to comply with the requests of state agents
faced physical harm including imprisonment and torture or corporal punishment
of themselves or their family members. According to one respondent, "the doctors
had no choice" and "were threatened with execution." Another physician expressed
the dilemma faced by these physicians: "What would you have done if you were
in the position of these physicians [who amputated ears]? What would you have
done, if you knew that if you refused, your ear would be cut, or you or your
family might be killed? Tell me honestly, what would you do?"
Respondents also cited the absence of national medical institutions
with power and independence to speak for, support, and protect individual
physicians and reported that under the repressive rule of the Baath party
in Iraq, medical institutions were either silent in the face of or complicit
in physician involvement in human rights abuses. Many physicians echoed the
words of one who said: "The Iraqi Medical Association . . . could not protect
the physicians from the government—it was part of the government." Physicians
said they felt they had no collective voice and thus virtually no political
power to exert in preventing human right abuses or in punishing those physicians
who participated willingly in abuses.
Most of the physicians interviewed had well-developed justifications
for physicians' involvement in abuses. Displacement of responsibility was
commonly expressed. Physicians argued that security officers, hospital directors,
and the United States, through its support of Saddam Hussein through 1991,
shared responsibility for human rights abuses. Some physicians explained their
involvement as mitigating the suffering of those abused. For example, one
surgeon, speaking of the forced nontherapeutic ear amputations of army deserters
that took place between 1994 and 1996, stated, "I couldn't refuse the decision,
it came from Saddam Hussein, but I refused the way it was being done in public."
Others accepted the bureaucratization of their role and denied any moral dimension
to their work as physicians. In the words of one, "At that time I only did
my job. I didn't ask [the cause of trauma of prisoners referred for treatment],
to protect myself. "
Our findings suggest that among those surveyed, participation in human
rights abuses involved a wide range of practices including nontherapeutic
partial or complete amputation of ears as a form of punishment, falsification
of medical-legal reports of alleged torture, and falsification of death certificates.
Self-reports of participation were much less common perhaps due to respondents'
psychological dissociation from their actions to preserve their sense of moral
Throughout the world, physicians have fought against human rights abuses.18- 20 Our interviews with
physicians in Iraq, however, suggest that the absence of independent national
medical institutions with power to speak for, support, and protect individual
physicians and the harm faced by Iraqi physicians who spoke out and their
families were powerful disincentives to physicians to resist participation
in human rights abuses. The participation of Iraqi physicians in abuses must
be understood in the context of the absolute control exerted by the Baath
regime. Fear of abuse may have been substantial, given the findings of another
PHR survey of randomly selected households in 3 cities in southern Iraq in
which 47% of households had at least 1 member who experienced a human rights
abuse since 1991.2
In general, repressive regimes' promotion of physician involvement in
abuses may create a fiction of power,21 sow
fear among the general population and/or specific groups,22 enable
officials to deny culpability,10 and serve
as a mechanism of moral disengagement for perpetrators.17 By
making medical professionals part of the machinery of repression, repressive
governments create an incentive for physicians to support the regime and undermine
trust among physicians and between physicians and the people for whom they
Participation of physicians in human rights violations contravenes international
standards of medical ethics25 and internationally
accepted statements by the World Medical Association, including the Declaration
of Geneva26 and the Declaration of Tokyo.27 While these standards represent the ethical ideal,
it seems unlikely that most physicians who participated in abuses had a choice
given the context in Iraq of governmental control, widespread abuses, and
the lack of protections of human rights under the Baath regime. In fact, physicians
who were forced to participate in abuses in Iraq may themselves be viewed
as survivors of an abusive regime and should not be considered to have the
same degree of culpability as their willingly complicit peers.
Health and human rights are inextricably linked and the protection of
human rights is an essential duty of physicians to prevent and alleviate human
suffering and promote health.28 Furthermore,
violations of human rights may have devastating health consequences, and,
as such, are of concern to physicians. Iraq is a party to The International
Covenant on Civil and Political Rights, which prohibits torture.29 Although
Iraq is not a party to the UN Convention Against Torture, the prohibition
of torture is considered jus cogens, a peremptory
norm of international law to which all states are bound and from which no
derogation is permitted.30- 33 While
participation of physicians in human rights abuses was mandated by edicts
promulgated by the Baath regime,6 these acts
also violated Iraq's Interim Constitution of 199034 and
the Iraqi Penal Code.35
As Iraq rebuilds, it is essential that the country address these violations
and take measures to prevent their recurrence. Legal reform, the strengthening
and reformation of medical institutions and associations, and implementation
of measures to ensure the independence of physicians from state authorities
are important. Increased human rights and ethics education for medical professionals
is necessary to address physician participation in abuses as is effective
monitoring of compliance with ethics and human rights standards. These measures
may help prevent some participation in abuses in the future. Finally, strategies
for remedies to address situations in which physicians find themselves under
threat if they do not comply with regime abuses may have a more direct impact,
including the formation and use of networks equipped for rapid mobilization
to support these physicians through exertion of international (governmental)
pressure on the abusive regime.
The experience of other countries that underwent or are undergoing periods
of transition may be instructive as to the range of possible approaches to
achieve accountability for and address past violations. Truth-telling by representatives
of health professional institutions about the role of the profession in abuses
in Iraq, when linked to institutional reform of medical associations,36- 38 may be an important
aspect of reformation of the medical profession in Iraq. The majority of Iraqi
physicians in this study supported punitive sanctions for those who commit
torture and/or ill treatment in the future. Trying those physicians in positions
of power who willingly aided and abetted the regime and who may have been
responsible for forcing other physicians to be complicit may deter future
abuses and help rebuild trust among physicians and between physicians and
Our findings cannot be generalized beyond the study population who were
primarily Shi'a Muslims, a group that was treated particularly harshly by
the Baath regime, from 3 civilian hospitals in 2 cities in southern Iraq.
Also, the data may not have captured fully the experiences of physicians who
resisted participation in abuses, because such physicians may have been killed
or forced to flee or leave medical practice. It is possible that many of those
who engaged in abuses opted not to complete the survey, not respond to abuse-related
questions, or to misrepresent their experiences to avoid recrimination or
job loss. The small proportion of self-reports of participation is not consistent
with the reports of high rates of participation among physician peers, suggesting
that responses may have either exaggerated or downplayed the true situation,
or both. Reasons for such distortions may include fear of job loss, shame,
guilt, denial, peer and other social pressures, and personal political views.
Additionally, the reports of colleague involvement do not include details
such as numbers involved or dates of abuses, so these higher figures may represent
multiple reports about the same individual or incident.
Despite the methodological limitations of this study, our data provide
critical insight into the nature of physician participation in a wide range
of human rights abuses in Iraq during the Baathist regime and the problems
experienced by these physicians. As Iraq rebuilds, it is essential that the
country, and other nations, address these violations and take a variety of
measures to prevent their recurrence.