CIA Memo: OMS Guidelines on Medical and Psychological Support to Detainee Rendition, Interrogation, and Detention

FAX COVER SHEET ceiiiiiMilili..747, ...., k e, il r ‘ (it 0 V 'S1.. t.'• F1 I u .1 Washington, DC 20505 15 Janua 2005 To: DOJ Command Center For Dan Levin Organization: Office of Legal Counsel . TT g nminrtnient of Justice Phone: i DOjCC Stu-IDL From. Organization: Phone: Fax: Number of pages (including cover sheet): 35 Comments: Onvui) Dan, Latest MKS Guidelines (came out while I was out of the office. I haven't studied to see what changed from the last version I sent you.' No cm: This information is proper0 ofthe UAW Stoles intmuied solely foam tat of the privileged or ogrerwin examPt front disclosure under applicab Offii0,r ar parade flan; ad above agent above mu I afro ineY be eiturneY'dieni responsible for daivering the massage the intended recliten, le law. (Oyu are not the intended recipient ofthisfaaindle, or the employee or o I any applioabk privilege or exemption .from dirchnnz ond that you are hereby notified Thai receipt of this =map Is not a wgiver or rdease Y. review, dissemination, distribution. or copying °filar communication is suiciO ' e Yeu have redelYed this' material in error. Ale notiOthis etc e a t the above rdephone number 4-siracrion. Thank you. , (callret)for instructions regarding its \ 0 \ P. b T ET OMS GUIDELINES ON MEDICAL AND PSYCHOLOGICAL SUPPORT TO DETAINEE RENDITION, INTERROGATION. :-\.ND DETEN'EON December 2004 'The following guidelines offer general references for medical officers supportingthe rendition and detention of tenor fists captured and turned over to the Central Intelligence Agency for Mterrontion and debriefing. There are three different contextsin which these guidelines may be applied: (1) during the period of rendition and initial interrogation • 1 g the more SUS eriod of d briefinc, and (3) cation site, TOP -11.11E T S At it ir:av sedatt subsesue ITaFSDnif i nr SCCUrit-V NO.70. P.f0 TOP . TOP CRET 5 NO.273. P.11 DETENTION AND INTERROGATION General intake evaluation New detainees are to have a thorough initial rnedicai assessment the first Agency detention facility, with upon arrival at a complete, documented history and physicaladdressing in depth any chronic or previous medic - eSpeciall attend to al problems. This assessment should cardio-vascular. ulmonai neurolozical and findings. musculoskeletal Vital s' ns 6 NO. 370 p,12 1 7 NO.370. P.13 Captured terrorists turned over to the CIA, for interrogation may be subjected to a wide range of legally sanctioned techniques, all of which ara'also used on U.S. military personnel in SERE training programs. These are designed to psycholog,itally "dislocate" the detainee,' maximize his feeling of vulnerability and helplessness, and reduce or eliminate his will to resist our efforts to obtain critical intelligence, Sanctioned interrogation techniques must be specifically approved in advance by the Director, CTC in the case of each individual case. They include, in approximately ascending degree of intensity: Shaving Stripping Hooding Isolation White noise or loud music (at a decibel level that will not damage hearing) Continuous light or darkness Uncomfortably cool environment Dietary manipulation (sufficient to maintain general health) Shackling in upright, sitting, or horizontal position Sleep deprivation (up to 48 hours) Attention grasp Paclal hold . Insult (facial) slap Abdominal slap Sleep deprivation (over 42 hours) Water Dousing and tossing Stress positions --on knees, body slanted forward or backward --leaning with forehead on wall —leaning on fingertips against wall Walling Cramped confinement (Confinement boxes) Waterboard In all instances the general goal of these techniques is a psychological impact, and not some physical effect, with a specific goal of "dislocatringj his expectations regarding 8 TOP REIM." NO.370 Pl14 TOP the treatment he believes he will receive...." The more physical techniques are delivered in a manner carefully limited to avoid serious physical harm. The slaps, for example, are designed "to induce shock, s physical rprise, and/or humiliation" and "not to inflict cal pain that is severe or lasting, " To this end they must be delivered in a specifically prescribed manner, erg, with fingers spread. Walling is performed only against a springboard designed to be loud and bouncy (and cushion the blow). All walling and most attention grasps are delivered only with the subject's head solidly supported with a towel .to avoid extension-flexion injury. OMS is responsible for assessing and monitoring the health of all Agency detainees subject to "enhanced" interrogation techniques, and for determining that the authorized administration of these techniques would not be expected to cause serf serious orpermanent harm.' "DCI Guidelines" have been issued formalizing and these should be read directly. these responsibilities, Advance Headquarters approval is required to use any physical pressures; technique-specific advanced approval is required for all "enhanced" measures and is conditional on on-site medical and psychological personne1 2, confirming from directdetainee examination that the enhanced technique(s) is not expected to produce "severe physical or mental pain or suffering." As a practical matter, the detainee'sphysical condition must be such that these interventions will not lave lasting effect, and his psychological state strong enough that no severe psychological harm will result The medical implications of the DCI guidelines are discussed below. The standard used by the Justice Department for "mental" harm is "prolonged mental ban," i.e., "mental harm of some lasting duration, e.g., mental harm lasting months or years.""In the absence of prolonged mental harm, no severe mental pain or suffering would have been inflicted." Memorandum of August 1, 2002, p. 15. Unless the waterboard is being used, the medical officer can be a physician or a PA; use of waterboard requires the presence of a physician. the TOrBcTIZT s--;Th- NO . 370 P.15 T-Z5:5''aSCZ111111 Medical treatment Adequate medical care shall be provided to detainees, even those undergoing enhanced interrogation. Those requiring chronic medications should receive them, acute medical problems should be treated , and ade nate fluids and nutrition provided, The basic diet during the period of enhanced interrogation need not be palatable,but should include adequate fluids and nutrition, Actual consumption should be monitored and recorded, . Liquid Ensure (or equivalent) is a good way to assure that there is adequate nutrition. Individuals refusing adequate 'ds durin this sta e should • =ve • fluids administered at the earliest sl: s of deh dration If there is any question urine output also should be monitored and recorded about adequacy of fluid intake, . All medical officers remain under the • rofessionol obli:.tion, to do no harm, Medical officers must remai es of their obligation to prevent "severe physical or mental pain or suffering." Uncomfortabl cool environments Detainees can safely be piked in uncomfortabl cool environments for vat of time ran from hours to da 10 NO.370 TO RET I OT Core body temperature falls after more than 2 hours at an ambient tempera Lure of 750°F. At this temperature increased metabolic rate cannot compensateloss. The WHO recommended minimum indoor temperature is 18*C/64T. • for heat "thermoneutral zone" where minimal compensatory activity is reuired to The temperature is 2QT/68°F to 30°C/86T q maintain core Within the thermoneutral zone, 2PC/78'F is considered optimally comfortable for li individuals. clothea individuals and 30 °C/86°F for naked If there is any possibility that ambient temperatures are below the thermaneutrrange, they should be monitored and the actual temperatures documented, At ambient temperatures below 1 8°C/64°F, detainees should be monitored for develo ment of hotherrrda. the let mani ulation durinriinten-oeation During the interrogation phase, detainee diets may be modified to enhance compliance with interrogators and facilitate movement to the debriefingphase. Detainees health should not be jeopardized by Rich restrictions, however, so medical officers should attend to adequate fluid and nutrition intake, In general, daily fluid and nutritional requirements may be estimated using the following formulae: Fluid requirement; 35 n .d / kg day. Will alter with ambient temperature, level of activity, intercurrent illness. Monitoring temperature .body output and specific f fluid intake and of urine c gravity may be necessary when the medical officer suspects the detainee is becoming dehydrated. ii NO.370. P.17 TOI-;-1"15r;gT,1= Energy requirement (male): 900 + I Ox weight in kilograms for basal Kcal • requirement; multiply by 1.2 for sedentary activity level, 1,4 for moderate activity level. Widely available commercial weight loss prowains in the US employ diets of1000 Kcal / day for sustained periods of weeks or longer without required medic supervision in persons voltnitarily seeking to lose weiht; these and effective in inducing short term weight loss, Francg alsafehised medical ally Supervised programs may employ diets with even lower daily calorie provision (as low as 500 Kcal /day), but do entail some risk because of alterations in serum electrolytes. Should the interrogation team choose to limit the detainee's food intake, OMSrecommends a minimum intake of 1500 Koalories / day, recognizin g that intakes of Kcal are safe and sustainable for weeks at a time. The nutrients y may be presented as1,000 either a balanced liquid supplement, such as Ensure Plus (360 Kcal / can), or a reductio in the detainee's normal solid food intake. If enhanced interrogation methods are n .contemplated, a liquid diet is appropriate to minimize risk to the detainee of aspiration; a liquid diet is mandatory if use of the waterboard is being contemplated. Water dousin Mdical officers suld refer to ho gin• e es or a discussion of water dousing techniques,e applied using which allow for water to b CTC e either a hose connected to tap water, or a bottle or similar container as the -water source. Care must be taken to keep water away from the face to avoid risk of accidental ingestion or aspiration, OMS guidelines for exposure to water ace: 12 NO. 370 TOP RE1111111 • For water temperature of-41 F / S C ­total duration of exposure not to exceed 20minutes without drying and rewarming • For water temperature of 50 F / 10 C total duration of exposure not to exceed 40minutes without drying and rewartnin g. 4 For water temperature of 59 F / 15 C ­ minutes without drying and rewarmin total duration of exposure not to exceed 60 g. These standards are derived from submersion studies, and represent 2/3 of the time at which hypothermia is likely to develop in healthy individuals submerged in water, wearing light clothing. In our opinion, a partial dousing, with concomitant less total exposure and potential heat loss, would therefore be safe to undertake within these parameters. The total dousin time includes both the actual dousing and time in wet clothing. White noise or loud music As a practical guide; there is no permanent hearing risk for continuous, 24-hom.:a-day exposures. to sound at 82 dB or lower; at 84 dB for up to 18 hoUrs a day; 90 dB for up to 8 hours, 95 dB for 4 hours, and 100 dB for 2 hours. If necessary instruments can be provided to measure. these ambient sound levels. 13 Tr:7P ***--Ss‘gT111111111 N0.370. P.19 TOP. T Shacldin and roloneed standing Shackling in non-stressful positions requires only monitoring for the developm of pressure sores with a ro •riate treatment and ad Ustment of the shackles as re tilted.ent If the detainee is to be shackled standing with hands at or above the head as part of a Weep deprivation protocol), the medical assessment should include a pre-che ck foranatomic factors that mi ht influence how lona the arms could be elevated. Assuming no medical contraindications are found, extended periods (up to 48hours) in a standing position can be approved if the hands are no hi er than hea and weight is borne fully by the lower extremities. d level TOP.14 T royal for s e de privati .er se without reRa_rd to sh9c:Ilin •osition P. 21 The maximum rime frame unde -tiT x•bc fr /80 hours. iiiiued iep deprivation is NOTE: Examinations Dey­ oriled crr iqlf7:5 = 9,?-r?-ods cr:-c recording of current iiro-nhe• C shof41,1 include the ics •i?0zi: ciceo: and; ilo.7:1; , period, the speci7cs ofh!);. C brier r'st prerecied !his o s. (21S0 bP Crain ec)er.___ nenc CCOT:rinCzn.,-.Et bc:.:f2s .; Detainees can be Dlaced Lil av,':Kward bakes, cifc5Ty ,-_, -o,qructf_d for this Ina become a safehaven offering a LU Cd. 7 217:(2,1:13.-r1V efle,....;nvt. as they , T-asoi.,-- int-trrouTica. cniarmem.ent in the 16 NO.370. P.22 small box is allowable up to 2 hours. Confinement in the large box is limited to 8 consecutive hours, up to a total of 18 hours a day. Waterboard This is by far the most traumatic of the enhanced interrogation techniques. The historidal context here was limited knowledge of the use of the waterboard in SERE training (several hundred trainees experience. it every year or two, In the SER E model ) the subject is immobilized on his back, and his forehead and eyes covered with a cloth. A stem of water isdirected at the upper lip. Resistant subjects then have the cloth lowered to cover the nose and mouth, as the water continues to beappy saturating the cloth, and precluding the passage of air. Relatively little water enters the mouth. The occlusion (which may be partial) lasts no more than 20 seconds. On removal of the cloth, the subject is immediately able to breathe, but continues to have water directed at the upper lip to prolong the effect, This process can continue for several minutes, and involve up to 1,5 canteen cups of water, Ostensibly the primary desired effect derives from the sense of suffocation resulting from the wet cloth temporarily occluding the nose and mouth, and psychological impact of the continued application of water after the cloth Is removed. SERE trainees usually have only a single exposure to this technique, and never more than two. , SERE trainers consider it their most effective technique, and deem it virtual' irresistible in the trainin settin While SERB trainers believe that trainees are unable to maintain psychologicalresistance to the waterboard, our experience was otherwise. Sonic subjects unquestionably can withstand a large number of applications, with no immediatl disbernahle cumulative impact beyond their strong aversion to the experiencce. 17 NO.370. P.23 TC;;1---8-n4111111 The SERE training program has applied the waterboard technique (single exposure) to trainees for years, and reportedly there have been thousands of applications without significant or lasting medical complications. The procedure nonetheless carries some potential risks, particularly when repeated a large number of times or when applied to an individual less fit than a typical SEIZE trainee. Several medical dimensions need to be monitored to ensure the safety of the subject, In our limited experience, extensive sustained use of the waterboard can introduce new risks. Most seriously, for reasons of physical fatigue orpsyclu)logical resignation, the subject May simply give up, allowing excessive fillingg of tbe airays and w loss ofconsciousness, An unresponsive subject should be righted immediately, and the interrogator should deliver a sub-xyphoid thrust to expel the water. If this fails to restore normal breathing, aggessive medical intervention is required, Any subject who has reached this degree of compromise is not considered an appropriate candidate for the waterboard, and the physician on the scene can not concur in further use of the waterboard without specific C/OMS consultation and approval. A rigid guide to medically approved use of the waterboard in essentially healthy individuals is not possible, as safety will depend on how the water is applied and the specific response each time it is used. The followin based on very limited lcn g general medical guidelines are owledge, drawn from very few subj tense ects whose experience and response was quite varied. The represent only the medical g uideli legal also are operative and may be more restrictive. guidelines TOP 18 RET NO.370. ll'0p.‘g111111. P.24 A series (within a "session") of several relatively rapid waterboard medically acceptable in all health suh'ects s applications is ewer o long as there is no indication of some vulnerability Several such sessions per 24 hours have been employed without apparent na cal CQMplicatim The exact number of sessions cannot be medicallyprescribed, and will depend on the response to each; however, all medical officers must be aware of the Agency policy on waterboard exposure. As of December 2004, CTC guidelines limit such sessions as follows: "a. Approvals for use of the waterboard last for only 30 days. During that 30-day period, the waterboard may not be used on more than 5 days during that 30-day period two. b. The number of waterboard sessions during any given 24-hour period may not exceed c. A waterboard 'session" is the period of time in which a subject is strapped to the waterboard before being removed. It may involve multiple applications of wafer, A waterboard session may not last longer than two hours. d. An "application" during a waterboard session is the time period in which water is poured on the cloth being held en the subject's face. Under the DCI interrogation guidelines, the time of total contact of water with the face will not exceed 40 seconds. The vast majority of ti applications are less than 40 seconds, many for fewer than 10 seconds, Individual applications lasting 10 seconds or longer will be limited to no more than six applications during any one waterboard session, The Agency will limit the aggregateminutes In any one 24-hour period," of applications to no more than 12 By days 3-5 of an aggressive program, cumulative effects become a potential concern. Without any hard data to quantify' either this risk or the .advantages of technique, we believe that beyond this point continued intense waterboard appli thiscations may not be medically appropriate. Continued aggressive use of the waterboard beyond this point should be reviewed .b the HVT team in consultation with Head anusprior to any further aggressive use. 19 • • v.— %el • NQ. 370 NOTE,. In order to best inform fidure medical judgments and recommendations, it is important that every application of the waterboard be thoroughly documented: how long each application (and the entire procedure) lasted, how much water was used in the process (realizing that much splashes off), how exactly the water was applied, i f a seal was achieved, if the naso- or orophalynx was filled, what sort of volume was expelled, how long was the break between applications, and how treatment. the subject looked between each 20 1;;;Nr..1111111111 110.370. P.25 NO.370 P.27 -TOP TIIIIII 22 TOP NO. 370 P.31 26 P 2 T -- . -.....-.... —, • 4.....f ral NO . 370 P . 32 • DOJ OLC 001172 110.370 P.33 General references: In addition to standard medical works, medical officers should refer to theDepartinent of Justice Bureau of Prisons website at www.boo.eov, accessing"Central Office", then "Health . Services" to ­ view their clinical practice guidelines. Theseguidelines and policies are useful references for procedures in novel situations. Other standard references which medical officers may find useful include •"Standards for Health Services in Prisons",. a regular publication of the National Commission on Contetional Health Care, last revised in 2003. Clinical Practice inCorrectional Medicine, Michael Puisis, ed. Mosby Publishing, 1998, is a useful compendium of care for chronic and infectious health issues in the prison setting. NO. 370 P.34 Appendix A. Medical rationales for limitations on physical pressures Measure Medical Rationale for Limitation References Limitation Shaving None Standard hygiene measure None in other custodial settings; risk of skin infections Stripping Ambient:air Below this temperature WHO guidelinestemperature at hypothermia may developminimum 64 P/ 18 C Diapering Evidence of loss of Diapering commonly None skin integrity due to employed hi hospital andcontact with human other care settings wherewaste materials incontinence is an issue. Hooding None; Methodology used hi SERE training Isolation None Methodology used in SERE, prison settings 'White noise 79 dB max Prevention of permanent OSHA guidelineshearing damage for continuous noise ex Continuous Related to sleep Used in other settings light or deprivation darkness Uncomfortably 3 hours below 60 Requires monitoring for WHO guidelines;cool F/ 16 C, with development of "Wildernessenvironment monitoring for hypothermia; risk is Medicine" 4a' Ed,, development of patient-specific Ch 6 — Accidental hypothermia; use of Hypothermia; Ch 9water will further Immersion intolimit exposure time cold water Restricted diet Loss of 10°4 of 10% loss indicates BOP guidelines TOP CRETIM NO. 370 P TO:").-'613C.13ZT1111.1 body weight; or evidence of dehydration 48 hours standard; longer periods require medical monitoring Cessation upon evidence of hypothermia; ambient temperature minimum of 64 F 18 C; potable water Source 48 hours for standar TOP significant malnutrition and requires corrective action Prolonged standing likely to induce dependent cderna,Increase risk for DVT, cellulitis. Increased heat loss promoted by contact with water below 35 C; death can result from prolonged (i.e. 6 hour) exposure to 15 C water, 2 bra at 10 C, 1 hr at 5 C; hypothermia can be induced in 30 minutes with' 5 C /41 water, 45 minutes with 10 C 154 F water, and 60 minutes with 15 C 159 F water immersion. Immersion at temperatures below 25 C / 77 F will eventually be fatal over lime, Periods of sleep deprivation of 90+ hours have been shown to be safe and without long term sequellae in large groups, and 200+ hours in individuals; required recuperative period undefined. Note 0.5 C drop in body temperature, which may impact use of water. Sleep deprivation does degrade cognitive performance, may induce visual disturbances, may , reduce immune competence acutely, Taal Shaer g in -upright sitting or horizontal position Water dousing Sleep deprivation CTC guidelines; experience with 20+ detainees "Wilderness Medicine" 411I Ed., Ch 6 — Accidental Hypothermia; Ch 9 Immersion into cold water; Transport Canada, "Survival in Cold Waters", ?REAL Operating Instructions CTC Cniidelinea; Horn; 5. Why We Sleep NINDS/I\IIH web site NO. 370 P . 36 T {.71r**13S0.1111111111 Attention grasp Facial bold Insult slap Abdominal . slap , Correct technique; no preexisting injury likely to be aggravated Correct technique; no preexisting injury likely to be aggravated Correct technique; no preexisting injury likely to be aggravated Correct technique; no preexisting injury likely to be aggravated 111111111111111 PREAL Operating Instructions Attention to risks of PREAL Operating immobilization, including Instructions DVT, and claustrophobia; ensure adequate air flair, ambient temperature Risks include drowning or OMS Guidelines;near drowning; • hypothermia from water exposure; aspiration pneumonia, laryngospasm, 30 ' Walling Cramped ' confinement Waterboard Stress positions Correct technique; no preexisting injury likely to be aggravated Correct technique; 110 preexistingin hlely to be aggravated Correct technique; no preexisting injury likely to be aggravated Correct technique; no preexisting . injury likel to be agu avated. resusm .4 on capability immediately at band; potable water source 110. 370 P. 37 31 • NO.370. 13.3§ '..T737.6.-"'S?pgaziT 33