August 16, 2012 in U.S. Army
FMI 4-02.46 MEDICAL SUPPORT TO DETAINEE OPERATIONS
- 138 pages
- Distribution restricted to the DOD and DOD contractors only to protect technical or operational information from automatic dissemination under the International Exchange Program or by other means.
- November 2007
This field manual interim (FMI) establishes guidelines for medical support to detainee operations (DO) as part of the Army Health System (AHS) in the theater. It discusses command structure and staff operations necessary to provide medical support to detainees.
This FMI is designed for use by commanders and their staffs in the planning and execution of providing medical support to detainees. Field Manual Interim 4-02.46 is not a stand-alone manual and must be used in combination with other publications. These publications are noted throughout the manual and a consolidated listing is provided in the references.
This publication applies to the Active Army, the Army National Guard/Army National Guard of the United States, and the United States Army Reserve, unless otherwise stated.
It is DOD policy that the US military services will comply with the principles, spirit, and intent of the international law of war, both customary and codified, to include the Geneva Conventions. As such, captured or detained personnel shall be accorded an appropriate legal status under international law and conventions. Personnel in US custody shall receive health care consistent with the standard of health care that applies for US military personnel in the same geographic area.
1-39. The GPW describes acts that are prohibited under the Conventions and specifies that all detainees will receive humane treatment.
• Prohibited acts include killing, torture, medical/scientific experimentation, physical mutilation, removal of tissues/organs for transplantation, and causing serious injury, pain, and suffering.
• Torture can take many guises in wartime situations. Historically, it has been used to extract tactical information from an uncooperative EPW. However, it has also been applied for the sake of punishment and/or to inflict pain and suffering. Regardless of the rationale, the torture of EPWs is prohibited. Health care personnel, who administer drugs to facilitate interrogation or advise interrogators on the ability of an individual to withstand torture, can be considered complicit in that torture.
• Under current DOD policy, health care personnel cannot certify a detainee for torture but they can provide consultation to interrogators so long as they are not also detainee treatment providers.
• Medical care will be provided with the consent of the detainee. To the extent practicable, standards and procedures for obtaining consent will be consistent with those applicable to consent from other patients. Standard exceptions for lifesaving emergency medical care provided to a patient incapable of providing consent or for care necessary to protect public health, such as to prevent the spread of communicable diseases, will apply.
• The Detaining Power is prohibited from conducting medical and scientific experimentation on detained personnel. This prohibition arose from the experiences in World War II. Since the prisoner is in the custody of the Detaining Power, any consent to the experiment is suspect as the prisoner may feel coerced to provide consent. This prohibition does not extend to the introduction of new treatment regimens and/or pharmaceuticals when there is a substantiated medical necessity and withholding the treatment would be detrimental to the health of the detainee.
• Due to the nature of warfare, numerous combatants/noncombatants will sustain injuries that require amputation of the unsalvageable limb to save life. Amputation which is based on a medical necessity and conforms to existing standards of health care is not considered physical mutilation and therefore not prohibited. Refer to paragraph 3-81 pertaining to documenting serious injuries and paragraph 3-85 pertaining to medical photography.
• With advances in medical science, transplantation of organs in peacetime has become an accepted method of treatment for certain conditions. However, during wartime with the exception of blood and skin grafts, transplantation of organs is prohibited. Although the recipient’s health benefits from the transplant, the donor’s health status does not. As with the discussion of consent for medical experimentation, the consent of a donor in custody of the Detaining Power is suspect as he may feel coerced into providing consent by his status. Additionally, the transplantation of organs/tissue from cadavers is also prohibited as the practice could lead to allegations that donors were permitted to die in order to harvest their organs. Protocol I, which supplements the GWS for the protection of war victims, permit the exception of blood and skin grafts but provides stringent controls. Tissues obtained must be used for medical purposes, not research or experimentation. The tissue donor must voluntarily consent to the procedure and records must be maintained.
• One ethical issue may confront surgeons on the battlefield that does not have a clear answer. Protocol I reiterates the right of an individual to refuse to undergo a surgical procedure, even if that procedure would be lifesaving and falls within existing medical standards. A surgeon may feel that he is not ethically bound by a refusal in the case of a minor or of an individual whose judgment is impaired by injury or illness. Documenting the issue, whether it is the patient’s refusal (in writing if at all possible) or the surgeon’s decision is an essential step in ensuring that allegations of abuse are not forthcoming.
ASSISTANCE PROVIDED TO INTERROGATION TEAMS
1-40. Under the provisions of the Geneva Conventions, health care personnel are prohibited from engaging in acts that are considered harmful to the enemy. Therefore, health care personnel providing direct patient care for detainees will not provide assistance to detainee interrogation teams. However, health care personnel must also consider the welfare of their patients. If a detainee has a medical condition which could deteriorate during interrogation and result in a health crisis for the detainee, the health care provider should inform the interrogation team of existing medical limitations. For example, a detainee who is a diabetic may have dietary restrictions and requirements, as well as a need to take medications on a scheduled basis.
1-41. Health care personnel charged with any form of assistance with the interrogation process, to include interpretation, of medical records and information will not be involved in any aspect of detainee health care. Health care providers charged with the care of detainees should not engage in any activities that jeopardize their protected status under the Geneva Conventions. Health care providers charged with the care of detainees should not be actively involved in interrogation, advise interrogators how to conduct interrogations, or interpret individual medical records/medical data for the purposes of interrogation or intelligence gathering. Health care providers who are asked to perform duties they feel are unethical should ask to be recused. Requests for recusal should first go to the health care provider’s commander and chain of command. If the chain of command is unable to resolve the situation, providers should engage the technical chain by contacting the detainee operations medical director (DOMD) or command surgeon. If these avenues are unfruitful, health care providers may contact their specialty consultants or the Inspector General (IG).
1-42. As a matter of personnel management policy, except as provided in this paragraph, health care personnel’s support of DO is limited only to providing services in a professional provider-patient treatment relationship in approved clinical settings, conducting disease prevention and other approved public health activities, advising proper command authorities regarding the health status of detainees, and providing direct support for these activities. Health care personnel will not be used to supervise, conduct, or direct interrogations. Health care personnel assigned as, or providing direct support to, behavioral science consultation teams (BSCT), consistent with Armed Forces Medical Examiner personnel, are the only authorized exceptions to this paragraph. The Assistant Secretary of Defense for Health Affairs (ASD[HA]), or designee, must approve any other exceptions to this paragraph. Behavioral science consultants—
• Are authorized to make psychological assessments of the character, personality, social interactions, and other behavioral characteristics of detainees, including interrogation subjects and, based on such assessments, advise authorized personnel performing lawful interrogations and other lawful DO, including intelligence activities and law enforcement. They employ their professional training not in a provider-patient relationship, but in relation to a person who is the subject of a lawful governmental inquiry, assessment, investigation, interrogation, adjudication, or other proper action. Requirements in this instruction applicable to behavioral science consultants are also applicable to other health care personnel providing direct support to behavioral science consultants.
• May provide advice concerning interrogations of detainees when the interrogations are fully in consonance with applicable law and properly issued interrogation instructions are available.
• May observe, but shall not conduct or direct, interrogations.
• May provide training in listening and communications techniques as well as skills needed to interpret results of studies and assessments concerning safe and effective interrogation methods and potential effects of cultural and ethnic characteristics of subjects of interrogation.
• May advise command authorities on the detention facility environment, organization and functions, ways to improve DO, and compliance with applicable standards concerning DO.
• May advise command authorities responsible for determinations of release, continued detention of detainees, or assessments concerning the likelihood that a detainee will, if released, engage in terrorist, illegal, combatant, or similar activities against the interests of the US.
• Will not support interrogations that are not conducted according to applicable law.
• Will not use or facilitate directly or indirectly the use of physical or behavioral health information regarding any detainee in a manner that would result in inhumane treatment or not be in consonance with applicable law.
• Ensure that detainees do not obtain the mistaken impression that health care personnel engaged in clinical care of detainees are also assisting in interrogations. Behavioral science consultants will not allow themselves to be identified to detainees as health care providers. Behavioral science consultants will not provide medical care for staff or detainees (except in emergency circumstances in which no other health care providers can respond adequately to save life or prevent permanent impairment).
• Will not provide training in first aid, sanitation, or other health matters. Absent compelling circumstances requiring an exception to the rule, health care personnel will not within a three-year period serve in the same location both in a clinical function position and as a behavioral science consultant.
• Will not provide medical screening (which is a health care function) to detainees nor act as medical monitors during interrogation.
• May consult at any time with the psychology or other applicable specialty consultants designated by The Surgeon General concerned for this purpose regarding the roles and responsibilities of behavioral science consultants and procedures for reporting instances of suspected noncompliance with standards applicable to DO.
• As a matter of professional personnel management, physicians are not ordinarily assigned duties as behavioral science consultants, but may be so assigned, with the approval of the ASD(HA) in circumstances when qualified psychologists are unable or unavailable to meet critical mission needs.
1-43. A psychologist, who is the behavioral science consultant, is assigned to DO. This person assists interrogators and the detention staff with interrogations and the management of detainees within the facility and is not assigned a mission of patient care. The medical treatment team should not consult with the BSCT on issues of treatment. Behavioral science consultation team members will not have access to medical records or any information about a detainee’s medical treatment except as needed to maintain safe, legal, and ethical interrogations. For example, it may be helpful to advise the BSCT that a detainee has diabetes and should not be provided certain types of food during interrogation. The BSCT will not provide treatment, except in emergency, and will inform the medical treatment staff of any medical issues needing attention.
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