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Table 1. Human Rights Abuses in Iraq and Physician Participation
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Table 2. Frequency With Which Respondents Reported That Physicians in General, Including Peers, Were Forced to Participate in Abuses
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Table 3. Respondent Reports of Self-participation in Human Rights Abuses
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Table 4. Medical Ethics
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Table 5. Opinions on Responses to Human Rights Abuses by Physicians
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1.
 UN General Assembly Resolution A/Res/54/178. Human Rights Situation in Iraq, A/54/PV.83. Adopted December 17, 1999, revised February 2000. Available at: http://ods-dds-ny.un.org/doc/UNDOC/GEN/N00/279/29/PDF/N0027929.pdf?OpenElement. Accessibility verified February 25, 2004.
2.
Amowitz LL, Kim G, Reis C, Asher JL, Iacopino V. Human rights abuses and concerns about women's health and human rights in southern Iraq.  JAMA.2004;291:1471-1479.
3.
Court C. Doctors in Iraq face amputation dilemma.  BMJ.1994;309:760.PubMed
4.
Butt G. Iraqi doctors face climate of fear.  BMJ.1994;309:898.
5.
Al-Shawaf T, Rawaf S. Human rights in Iraq.  BMJ.1995;310:130.
6.
Amnesty International Web site.  Systematic Torture, Execution and Punitive Surgery: Iraq. Medical letter writing action. August 15, 2001. Available at: http://web.amnesty.org/library/Index/ENGMDE140102001?open&of=ENG-IRQ. Accessed August 24, 2003.
7.
Amnesty International Web site.  Iraq: state cruelty: branding, amputation and the death penalty. 1996. Available at: http://web.amnesty.org/library/Index/ENGMDE140031996?OpenDocument&of=COUNTRIES/IRAQ?OpenDocument&of=COUNTRIES/IRAQ. Accessed August 24, 2003.
8.
World Gazetteer Web site.  Iraq 2004. Available at: http://www.world-gazetteer.com/fr/fr_iq.htm. Accessibility verified February 25, 2004.
9.
 Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. GA Res 39/46 [annex, 39 UN GAOR suppl No. 51 at 197, UN Doc A/39/51 (1984)]. Entered into force June 26, 1987.
10.
Iacopino V, Heisler M, Pishevar S, Kirschner RH. Physician complicity in misrepresentation and omission of evidence of torture in postdetention medical examinations in Turkey.  JAMA.1996;276:396-402.PubMed
11.
Heisler M, Moreno A, DeMonner S, Keller A, Iacopino V. Assessment of torture and ill treatment of detainees in Mexico: attitudes and experiences of forensic physicians.  JAMA.2003;289:2135-2143.PubMed
12.
Patton MQ. Qualitative Evaluation and Research Methods. Newbury Park, Calif: Sage Publications; 1990:169-283.
13.
 Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects . 5th Rev Ed. Ferney-Voltaire, France: World Medical Association; 2000.
14.
 STATA 7.0 (Intercooled) for Windows. College Station, Tex: STATA Corp; 2002.
15.
Global Security.org Web site.  Saddam's martyrs, Fedayeen Saddam. Available at: http://www.globalsecurity.org/intell/world/iraq/fedayeen.htm. Accessed December 3, 2003.
16.
Central Intelligence Agency Web site.  CIA factbook: Iraq, military branches. Available at: http://www.cia.gov/cia/publications/factbook/geos/iz.html. Accessed December 3, 2003.
17.
Bandura A. Mechanisms of moral disengagement. In: Reich W, ed. Origins of Terrorism: Psychologies, Ideologies, Theologies, States of Mind. New York, NY: Cambridge University Press; 1990:161-191.
18.
Geiger HJ, Cook-Deegan RM. The role of physicians in conflicts and humanitarian crises: case studies from the field missions of Physicians for Human Rights, 1988 to 1993.  JAMA.1993;270:616-620.PubMed
19.
Rubenstein LS. Physicians and the ethic of human rights.  Minn Med.1999;82:46-48.PubMed
20.
British Medical Association.  The Medical Professions and Human Rights: Handbook for a Changing Agenda. London, England: Zed Book; 2001.
21.
Scarry E. The structure of torture: the conversion of real pain into the fiction of power. In: Scarry E. The Body in Pain: The Making and Unmaking of the World. New York, NY: Oxford University Press; 1985:27-59.
22.
Eitinger L, Weisaeth L. Torture: history treatment and medical complicity. In: Jaranson JM, Popkin MK, eds. Caring for Victims of Torture. Washington, DC: American Psychiatric Press; 1998:7.
23.
Iacopino V, Rosoff R, Heisler M. Torture in Turkey and Its Unwilling AccomplicesBoston, Mass: Physicians for Human Rights; August 1996.
24.
International Dual Loyalty Working Group.  Dual Loyalty & Human Rights: In Health Professional Practice: Proposed Guidelines and Institutional MechanismsCape Town, South Africa: Physicians for Human Rights and School of Public Health and Primary Health Care, University of Cape Town, Health Sciences Faculty; 2003.
25.
World Medical Association.  Declaration of Geneva. 1983. Available at: http://www.wma.net/e/policy/c8.htm. Accessibility verified February 25, 2004.
26.
UN General Assembly.  Principles of Medical Ethics Relevant to the Protection of Prisoners Against Torture. 1983. Resolution 37/194 (Principles of Medical Ethics). Adopted December 18, 1982. Available at: http://www.un.org/documents/ga/res/37/a37r194.htm. Accessibility verified February 25, 2004.
27.
World Medical Association.  Declaration of Tokyo. 1975. Available at: http://www.wma.net/e/policy/c18.htm. Accessibility verified February 25, 2004.
28.
Mann JM, Gostin L, Gruskin S, Brennan T, Lazzarini Z, Fineberg H. Health and human rights. In: Mann J, Gruskin S, Grodin M, Annas G, eds. The Health and Human Rights Reader. New York, NY: Routledge; 1999:7-28.
29.
 International Covenant on Civil and Political Rights. GA Res 2200A (XXI), 21 UN GAOR Suppl (No. 16) at 52, UN Doc. A/6316 (1966), 999 UNTS 171. Entered into force March 23, 1976.
30.
American Law Institute.  Restatement (Third) of the Foreign Relations Law of the United States, 1987 §702.
31.
Bassiouni MC. International crimes: jus cogens and obligatio erga omnes.  Law Contemp.1996;59:63, 68.
32.
Brownlie I. Principles of Public International Law5th ed. Oxford, England: Oxford University Press; 1998.
33.
 Prosecutor v Anto Furundzija , International Criminal Tribunal for former Yugoslavia, Case No IT-95-17/1-T, Trial Chamber. Judgment of December 10, 1998: 153-157. Available at: http://www.un.org/icty/furundzija/trialc2/judgement/index.htm. Accessed August 27, 2003.
34.
International Constitutional Law Web site.  Interim constitution of Iraq. 1990. Article 22 (a). Available at: http://www.oefre.unibe.ch/law/icl/iz00000_.html. Accessed January 5, 2004.
35.
Amnesty International.  Torture in the EightiesLondon, England: Amnesty International Publications; 1984:231.
36.
American Association for the Advancement of Science.  Truth and reconciliation: examining human rights violations in South Africa's health sector. Submission to the Truth and Reconciliation Commission concerning the role of health professionals in gross violations of human rights. 1997. Available at: http://shr.aaas.org/trc-med/presub.htm. Accessibility verified February 25, 2004.
37.
Kimani D. At last, Kenyan doctors join war against torture.  The East African.May 15, 2000.
38.
Welsh J. Truth and reconciliation . . . and justice.  Lancet.1998;352:1852-1853.PubMed
Original Contribution
March 24/31, 2004

Physician Participation in Human Rights Abuses in Southern Iraq

Author Affiliations

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).

JAMA. 2004;291(12):1480-1486. doi:10.1001/jama.291.12.1480
Context

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,37 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 involvement.

METHODS
Sampling

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.

Survey Instrument

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.

Interviews

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.

Human Subjects' Protections

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.

Statistical Analysis

The data were analyzed using STATA 7.0.14 Analysis consisted of descriptive analysis of means and proportions only.

RESULTS

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.

Sociodemographic Characteristics

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.

Physician Participation in Human Rights Abuses

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).

Respondent Awareness of Professional Ethics

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.

Opinions on Responses to Abuses by Physicians

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 5.

Semistructured Interviews With Iraqi Physicians

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. "

COMMENT

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 integrity.17

Throughout the world, physicians have fought against human rights abuses.1820 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 care.23,24

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.3033 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,3638 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 patients.

Limitations

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.

Conclusion

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.

References
1.
 UN General Assembly Resolution A/Res/54/178. Human Rights Situation in Iraq, A/54/PV.83. Adopted December 17, 1999, revised February 2000. Available at: http://ods-dds-ny.un.org/doc/UNDOC/GEN/N00/279/29/PDF/N0027929.pdf?OpenElement. Accessibility verified February 25, 2004.
2.
Amowitz LL, Kim G, Reis C, Asher JL, Iacopino V. Human rights abuses and concerns about women's health and human rights in southern Iraq.  JAMA.2004;291:1471-1479.
3.
Court C. Doctors in Iraq face amputation dilemma.  BMJ.1994;309:760.PubMed
4.
Butt G. Iraqi doctors face climate of fear.  BMJ.1994;309:898.
5.
Al-Shawaf T, Rawaf S. Human rights in Iraq.  BMJ.1995;310:130.
6.
Amnesty International Web site.  Systematic Torture, Execution and Punitive Surgery: Iraq. Medical letter writing action. August 15, 2001. Available at: http://web.amnesty.org/library/Index/ENGMDE140102001?open&of=ENG-IRQ. Accessed August 24, 2003.
7.
Amnesty International Web site.  Iraq: state cruelty: branding, amputation and the death penalty. 1996. Available at: http://web.amnesty.org/library/Index/ENGMDE140031996?OpenDocument&of=COUNTRIES/IRAQ?OpenDocument&of=COUNTRIES/IRAQ. Accessed August 24, 2003.
8.
World Gazetteer Web site.  Iraq 2004. Available at: http://www.world-gazetteer.com/fr/fr_iq.htm. Accessibility verified February 25, 2004.
9.
 Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. GA Res 39/46 [annex, 39 UN GAOR suppl No. 51 at 197, UN Doc A/39/51 (1984)]. Entered into force June 26, 1987.
10.
Iacopino V, Heisler M, Pishevar S, Kirschner RH. Physician complicity in misrepresentation and omission of evidence of torture in postdetention medical examinations in Turkey.  JAMA.1996;276:396-402.PubMed
11.
Heisler M, Moreno A, DeMonner S, Keller A, Iacopino V. Assessment of torture and ill treatment of detainees in Mexico: attitudes and experiences of forensic physicians.  JAMA.2003;289:2135-2143.PubMed
12.
Patton MQ. Qualitative Evaluation and Research Methods. Newbury Park, Calif: Sage Publications; 1990:169-283.
13.
 Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects . 5th Rev Ed. Ferney-Voltaire, France: World Medical Association; 2000.
14.
 STATA 7.0 (Intercooled) for Windows. College Station, Tex: STATA Corp; 2002.
15.
Global Security.org Web site.  Saddam's martyrs, Fedayeen Saddam. Available at: http://www.globalsecurity.org/intell/world/iraq/fedayeen.htm. Accessed December 3, 2003.
16.
Central Intelligence Agency Web site.  CIA factbook: Iraq, military branches. Available at: http://www.cia.gov/cia/publications/factbook/geos/iz.html. Accessed December 3, 2003.
17.
Bandura A. Mechanisms of moral disengagement. In: Reich W, ed. Origins of Terrorism: Psychologies, Ideologies, Theologies, States of Mind. New York, NY: Cambridge University Press; 1990:161-191.
18.
Geiger HJ, Cook-Deegan RM. The role of physicians in conflicts and humanitarian crises: case studies from the field missions of Physicians for Human Rights, 1988 to 1993.  JAMA.1993;270:616-620.PubMed
19.
Rubenstein LS. Physicians and the ethic of human rights.  Minn Med.1999;82:46-48.PubMed
20.
British Medical Association.  The Medical Professions and Human Rights: Handbook for a Changing Agenda. London, England: Zed Book; 2001.
21.
Scarry E. The structure of torture: the conversion of real pain into the fiction of power. In: Scarry E. The Body in Pain: The Making and Unmaking of the World. New York, NY: Oxford University Press; 1985:27-59.
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