Wasbington, DC J -...,~ 'DOJ Command Center 'For Dan Levin. Office of Legal Couns~ nan~yhh~ntofjnstlce -:J

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1 ~~ \ \ \ t \ \ To: Organzaton: , ~, Wasbngton, DC J -...,~ 'DOJ Command Center 'For Dan Levn. Offce of Legal Couns~ lt~ nan~yhh~ntofjnstlce -:J ~P..;..:;h~on;.;...;e;..;;,..! _~-, Fax: DOJCC Stu-ll From: Organzaton:. Phone: Fax: Number ofpag~ ncludng cover sheet): Comments: ~ Dan., Latest DVS Gudelnes ~ame out whle was.out of the offce. haven't studed to see what changed fr~m the last verson sent you... ; Nonp't TO RECfPrEN'f. Thl"n!ormotlon s pl'~pert,)j pj tt, {fnutd SWa ntcndd SDlelY/Of the ure )/tha mtly Dr pmd1j namul a[jdvlf tujd akf blay be trltpmey.ddll prlvlqrcd 111 otllerwut tx~p frdm quclosutt unda appllenhle mv.!flou at't 1ot flt hf~n"d recpler,f Qjths/l1.rffflfle, or the ~Mplt)}'ff ' agent rt.tpo1l$/bk for cjfdverng 1M mauaqt. 10 tht nlelukd recpenf, you ore ler:eby notfed rhal m:dpt of W /llc.jjag~ s no! Q wpfver Of rdcau 0/ anv applcoblt prvut:gc or!umptldn from dsclosure, Gld that 1'C"A~ tlsstmdnarjolj, clstrbuton. or copyttg ofhu communtcaton t strctly!,! Y!.. lfyou hav! n'~lw ths l'1faf!n'a n error. plea.rt MlfJY bs o.ffl~ tv de abdvd rejtphont fflmcu colfta) lor ttstrocdtjl1f t~gm:llng ts '~?tructto1. Thank you.,- \0\,, f \ t

2 "'J..:JfQ t'.b OMS GUDELNES ON l'vedcal AND PSYCHOLOGCAL SUPPORT TO DETANEE REl'<'DlTON, NTERROGATON, A\'D DETENTfON December 2004 The followng gudelnes offer general references for medcal otlcers supportng the rendton and detenton of terror ss captured and turned O\"er lo the Centra] ntellgence Agency for ntmogton and debrefng" There arc hree dfferent contexts n whch these gudelne" may be cppjed: 1) durng the perod of rendton and ntal nterro the more erod. on ste, and 3). ) 1

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5 . < - - <,-....Gudelnes :C~: tne ~, :JS~ ~':l S~~2:':'\ =S ~.-

6 NO. 378 P.10 l 5

7 NO. 370 P.l General ntake evalua.ton DETENON At-TD rnterj~ogaton New detanees are to have a thorough ntal lledcal assessment Upon arrval at the frst Agency detenton faclty, wtl! a complete, documented llstory and physcal addressng n depth any chronc or prevous medcal problems. Tns assessment should espec attend to carda-vascular ulmon3j lleurolodcal ffllscu!oskel fndngs. 6

8 to.370 P.12 r 7 1

9 NO. 370 P.13 c" nterrogatq"n, Captured terrorsts turned over to the C..A. for nterrogaton may be subjected to a \vde range oflega11y sanctoned technques, all of whch ~'a1so used on U.S. mltal'y personnel n SERB tranng programs. These are desgned to :psycholog~a11y udslocate H the detanee t maxmze hs feelng of vulnerablty and helple-ssness, and reduce or elmnate hs wll to resst our" efforts to obtan crtcal ntellgence.". Sanctoned nterrogaton teclmques Dl'Ust be specfcally approved n advance by the Drector, etc n the case of each ndvdual case. They nclude, n approxmately ascendng degree of ntensty: ) Shavng Strppng Hoodng solaton. Whte nose or loud musc at a decbel level "that "\vll nat d8.tp.age hearng) Contnuous lght or darkness Uncomfortably cool envronment. Detary manpulaton suffcent to mantan general health) Shacklng n upr1gh~ sttng, or horzontal poston Sleep deprvaton up to 48 hours) Attenton grasp Facal hold nsult facal) slap Abdomnal slap Sleep deprvaton over 48 hours) Water D<;lusng and tossng Stress postons -.. on knees) body slanted forward or backward -.leanng \vfu forehead on "wall.,-leanng on fngertps aga11st wall Wallng Cramped confnement Confnement boxes) Waterboard n all nstances the general goal of these t~cbnques s a psychologcal mpact, and. not some physcal effect, \Vth a specfc goal ofcfdslocat[ng] hs expectatons regardng 8

10 ' the treatn1ent he beleves he wll receve.. un The more physcal technques are. delvered n a manner carefully lmted to avo.d serous physcal hann. The slaps, for example, are desgned Uta nduce shock, surprse. and/or humlatlon u and "not to nflct physcal pan that s severe or lastng.".. To ths end they must be delvered n a specfcally prescl1bed manner) e.g. wjl fnger-s spread. Wallng s performed only aganst a sprngboard desgned to be loud and bouncy and cushon the blow). All wallng and most attenton grasps are delvered only 'wth the subject's head soldly supported t 1th a towel,to avod extenson-flexon njury.. OMS s responsble for assessng and mopjtorng the health of au Agency d~ta.nees subject to "enhanced>l nterrogaton technques, and for detennnng that the authorzed admnstraton of these technques would not be expected to cause serous or permanent harm.' unc Gudelnes" have been ssued formalzng these responsbltes) and these should be read drectly.. Advance Headquarters approval s requred. to use any physcal pressures; tecrulque"specfc advanced a.pproval s requred for all "enhanced tt. measures and s condtonal on on-ste medcal and psychologcal personne1 2. conftmng from drect detanee examnaton tht the enhanced teohnques) s not expected to produce "severe physcal or mental pan or sufferng.t As a practcal matter, the detanee's physcal condton nust be such that these nterventons wll not'have lastng effect, and hs psychologcal state strong enough that no severe psychologcal harm wll result V'. ~ The standard used by the Justce Department for Umentar' hann s ''prolonged mental hann/'.e.) Hmental harm of some lastng duraton, e.g. t mental harm lastng months or yeats:' "n the absence of prolonged mental harm, no severe menrol pan or sufferng would have been nflcted." Memorandum of August ) 2002, p. 15. Unless s beng used] the m~llcal waterboard requres the presence of a physcan. can be a physcm or apa; use of the T~T

11 HO.378 P.1S Medcal treatment Adequate medcal care shall be provded to detanees, even those undergong enhanced nterrogaton. Those requrng chronc. medcatons should receve acute medcal should be and aaelqua:te The basc det durng the perod of enhanced nterrogaton need not be palatable, but should nclude adequate fluds and nutrton. Actual consumpton should be montored and teco~ded. ' Lqud Ensure or eq\lvale~t) s a good way to assure that there s adequate nutrto~ ndvduals refusng ad~quate ths fluds admnstered at the est of r{o.h,,,,jt'~-h'" f there s any queston about adequacy of should be montored and recorded. must reman cognzant at al tmes ere physcal or mental pan or sufferng. u Uncomfortably cool envronments. 10

12 NO. 370 P.16 Core body temperature falls after more than 2 hours at an ambent temperature of 1 QOC/50 F At ths temperature 'ncreased 'metabolc rate cannot compensate 'for heat. loss. The WHO recommended mnmum ndoor temperature s 18 C/64 P." The "thermonelltral"zone" where mnmal compensttory aotvty s requred to mantan core temperature s 20~C/68 F to 30 C/86 P t Wthn th~ thermoneutral zone, 26 C/78 F s consdered e for clothed ndvduals and 30 C/86 F for naked f there s any possblty that ambent temperatures are belo,,, the the;1'lnon~~u~ru range, they sh:ould be montored and the actual documented. ) At ambent temperatw"es below 18 C/64 F detanees should be montored for the ""r..~"q-n"" of. petary manp~aton durng' nterro2:aton Durng the nterrogaton phase, detanee dets may be modfed to enhance complance wth nterrogators and facltate movement to the debrefng phase, Detanees health should not be jeopardzed by such res1rctons, however) so medcal offcers should attend to adequate flud and nutrton ntake. n general, daly flud and nutrtonal requh'ements may be estmated usng the follo-wng formulae:. Flud requrement; 35 m1 / kg day. Wll alter wth ambent temperarure;body temperature) level of actvty, ntercurrent llness. Montorng of flud ntake and of urne output and specfc gravty may be necessary when the medcal offcer suspects the detanee s becomng dehydrated. 11 \ \!!

13 NO.370 P.l7 Energy requrement male); lox weght n ldlograms for basal Kcal requrement; multply by 1.2 for sedentary actvty level) 1 A for moderate act'vty level.. Wdely avalable commercal weght loss programs n the US employ dets of 1000 Kca day for sustaned perods of weeks or longer w;.thout requred medca~ supervson n persons voluntarly seekng to lose \veght; these dets have proven safe and effectve n nducng short tenn weght Franchsed medcally supervsed. programs may employ dets \vth even lower daly calore provson as low as 500 Kcal / day), but do ental some rsk because of alteratons n serum electrolytes. Should the ntel1'ogaton team choose to lmt the detanee's food ntake, OMS reconullends a mnmum ntake of 1500 Kcalores day, recognzng that ntakes of 1,000 Keal are safe and sustanable for weeks at a tme. The nutrents may be presented as ether a balanced lqud supplelnent J such as Ensure Plus 360 Kcall can), or a reducton j n the detanee) s normal sold food ntake. f enhanced nterrogaton methods are.contemplated, a lqud det s approprate to nn;mjze rsk to the detanee of aspraton; a lqud det s mandatory f use of the walorboard s beng contemplated... \! Water dousjng l\1edcal offcers should refer to etc gut of water dousng technques, whch allow for water to be appled usng ether a hose connected to tap water, or a bottle or smlar contaner as the - water source Care must be taken to keep water away from the face to avod rsk of accdental ngeston or aspraton. OMS gudelnes for exposure to water are: 1.2 \! l \

14 P.1S.g For water temperature of 41 F 15 C - total d~aton of exposure not to exceed 20 mnutes wthout and rewarmng.. For water temperature of 50 F 110 C oj total duraton of exposure not to exceed 40 mnutes wthout dlyng and rewarmng. o For 'Vater temperature of 59 F 115 C - total duraton of exposure not to exceed 60 mnutes wthout dryng and rewannng. These standards are derved from submerson studes! and repre.sent 2/3 of the tme at. whch hypotherma s lkely to develop n healthy ndvduals submerged n water, \vearng lght clothng. n our opnon, a pattal dousmg t wth concomtant less total exposul'e and potental heat loss, would therefore be safe to undertake wthn these pru"8l).et.ers. ~t ~~ Whte nose or loud luusc As a practcal gude~ there s no permanent hearng rsk for contnuous, 24-hours': 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 l 95 db for 4 hours, and 100 db for 2 houts. f nstruments can be provded to measure. these ambent sound levels \,! 13

15 HO.370 P.19 " Shacklng and prolon~ed standng Shacklng n non-stressful postons requres only montorng for the development fp e ~th t tr. tn t d d'ustm t fth h kl d f the detanee s to be shackled standng wth hands at or above the head as part of a sleep deprvaton protocol), the medcal as~essment should nclude a pre-check anatomc factors that nfluence how the arms Assumng no medcal contrandcatons are found, extended perods up to 48 hours) n a standng poston can be approved f the hands are no than head level and weght s borne the lower extremtes. /. ; \ 1 14 \ " t

16 Sleep deprvcton. \! j.!. l!

17 The maxmum t 180 hours. f..

18 HO.370 P.22 small box s allowable up to 2 hours. Confnement n the large box s lmted to 8 consecutve hours, up to a total of 18 hours a day. Waterboard Ths s by far the most traunlatc of the enhanced nterrogaton technques. The hstorcal context here was lmted knowledge of the use of the waterboall n SERE tranng several hundred tranees experence. t. every year or nvo).. n the SERE model the subject s mmoblzed on hs back, and hs forehead and eyes c.overed \vth a cloth. A stream of water s.drected at the upper lp. Resstant subjects then have the cloth lowered to cover the nose and mouth~ as the water contnues to be appled,' fully saturatng the cloth, and p~ecludng the passage of ar. Relatvely lttle water enters the mouth. The occluson wbjch may be partal) lasts no more than 20 seconds. On removal of the cloth, the subject s mmedately able to breathe, but contnues to have water drected at the upper lp to prolong the effect. Ths process can ~ntnue for several mnutes, and nvolve up to 15 canteen cups of water. Ostensbly the prmary desred. effect derves from the sense of suffocaton roswtng from the wet cloth temporarly occludng the nose and mouth, and psychologcal mpact of the contnued appllcat~n of water after the cloth jg removed. SERE tranees usually have only a sngle exposure to ths technque, and never more than two; SERE traners consder t ther most effectve.tecm and deem t rresstble n. Vlhle SERE traners beleve that tranees are unable to mantan psychologcal resstance to the waterboard J our experence was otherwse. Some subjects. unquestonably can wthstand a large number of applcatons, -wth DO fllljl1ec11ate,lv dscernable oumulatve. ther averson to the exp:enelclce. 17

19 1' P. 23 The SERE tranng progt'am has appled the waterboard technque sngle exposure) to tranees for years) and reportedly there have been thousands of applcatons \'tjthout sgnfcant or lastng medcal complcatons. The procedure nonetheless carres some potental rsks, partcularly when repeated a large number of tmes or \vhen appled to an ndvdual less ft than a typcal SERE tranee. Several medcal dmensons need to be montored to. ensure the safety of the subject. n our lmted experence, extensve sustaned use of the waterboard can ntroduce ne\v rsks. Most serously, for reasons of physcal fatgue Or psychologcal resgnaton, the subject may shnply gve up, allowng excessve fllng oftbe arways and loss 9 conscousness. An unresponsve subject should be rghted nnnedately, and the nterrogator should delver a sub-xyp~od thrust to expel the water. f ths fals to restore normal breathng) aggressve medcal nterventon s requted. Any subject who has reached ths degree of compromse s not consdered an approprate canddate fo~ the waterboard, and the physcan on the scene can not concur n further use of the waterboard wthout specfc C/OMS col1sultaton and approval. A rgd gude to medcally approved use of the waterboard n essentally healthy ndvduals s not possble, as safety wll depend on how the \vater s appled and the. specfc response each tme t s used. The followng general medcal gudelnes are based on very lmted knowledge. drawn from very few subjects whose experence and response was qute vared. These represent only the medcal gudelnes; legal gudelnes also are operatve and may be more restrctve. 19 \!.!

20 NO. 370 P.24 A seres wthn a "sessonll) of several relatvely rapd v/aterboard applcatons s lnedcally acceptable all of some LJ...,L.T'""T" ~... vulnerab Several such sessons per 24 hours been apparent complcatolt The exact"number of sessons cannot be medcally prescnoed, and wll depend on thy re~ponse to each; however, all medcal offcers must be a'ware of the Agency polcy on waterboard exposure. ~ ofdecemher 2004, etc gudelnes lmt such sessons as follows: "a. Approvals for use of the waterboard last for only 30 days. Durng that 30-day perod, the waterboard may not be used on more than 5 days durng that 30-day pero!l two. b. The number ofwaterboard sessons durng any gven 24-hour perod may nqt exoeed e. A waterboard llsesson ll s the perod of tme n whch a subject s strapped to tho waterboard before bengl'emoved. t may nvolve multple applcatons of water. A waterboard sesson may not last longer than two hours. ) d.- An flapplcatonll durng a waterboard sesson s the tme per)d n whch water s po~ed on the cloth beng held on the subjecttg face. Under the DC nterrogaton gudelnes, the tme of totat contaot of water wth the face wll not exceed 40 seconds. The- vast majorty of applcatons are less than 40 seconds, many for fewer than 10 -seconds. ndv4ual applcatons lastng 10 seconds or longer wll be lhnted to no more than sx applcatons durng anyone waterboard sesson. The Agency wllllmt the aggregate of applcatons to no more than 12 ml'1ttes n anyone 24-hour perod.. '. - By-days 3-5 afan aggressve prog~ cumulatve effects become-a potental concern. \Vthout any hard data to quantfy ether ths rsk or the.advantages of ths techn que, we beleve that beyond ths pont contnued ntense '\vaterboard applcatons may not be medcally approprate. Contnue-d aggressve use of the water board beyond ths pont should be reve\ved... to any further aggressve u 19

21 MO. 378 P.25 }{OTE; n order to best nfonn future medcal judgments and rec01nmendatons, t s mportant that every applcltolf of the waterboard be thoroughly documented: how long each applcaton and the entre procedure) lasted t haw much }Vaterlvas used n the process realzng that m-uch splashes ofj), how exactly the waer was appled, b" a seal was acheved, f the nas) or oropharynx was flled} what sort of volume was e:cpelletl ho'tv long r~q's the break bern 1 een applcatons, and how the subject looked betrveen each treatment. \ / \ 20

22 NO. 370 P.25 c c 21!! f

23 NO. 370 c 22

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27 NO.37B P.31 26

28 ,. c...f rloj NO. 370 P.32 \ J

29 -., -_... ~,,; "'t. c.r rrl NO. 370 P.33 General re.ferences: n addton to standard medcal works, medcal offcers should refer to the"department of Justce Buteau of Prsons,vebste at W\vw.boD.eov, accessng "Central Offce"l then ''Health" Servces" to vew ther clncal practce gudelnes. These gudelnes and polces are useful references for'procedures n nove). stuatons, Other standard references whch medcal offcers may fnd useful nclude,"standards for Health Servces n Prsons!t,. a regular publcaton of the Natonal Co:tn.msson on Con"ectonal Health Care, last revsed n Clncal Practce n Correctonal A{edc1Je~ Mchael Puss, edt 1vlosbyPublsbng, 1998, s a useful co~pendum of care for cb'onc and nfectous health ssues n the prson se~g., J t 21

30 L.~ ' C.or1'l l'kl.370 P.34 Appendx A. Medcal ratonales for ~tatons on ph'y~cal pressures!\treasure Shavng Strppng Daperng R:oodng lvledcal Lmtaton None' Ambent ~ ar temperature at mnmum. 64 F 18 C Evdence of loss of skn ntegrty due to contact wth human w-aste materals Ratonale for Lntaton Standard hygene measure n other custodal sethngs; rsk ofskn nfectons Below ths temperature hypotherma may develop Daperng commonly employed n hosptal and other care settngs wllere ncontnence s an ssue. lyfethodology used n SERE tranng References None \VHO gudelnes None \ \ solaton Methodology used n SERE, prson settngs 'Whte nose 79 db max Preventon of pennanent hearng daolage gudelnes for contnuous. Contnuous lght or darkness Related to sleep deprvaton Used n oth'er settngs Uncomfortably cool envronment Restrcted det <3 hours b~low 60 F 116 C, 'v1th montotjng for development of hypotherma; use of water v,ll further lmt exposure tme' Loss of 1 O~l, of Requres montorng for development of h)1?otherrrrla;rsks patent-specfc 10% loss ndcates VlHO gudelnes; '~Wldemess. Medcne" 4 fh Edt, Ch 6..:. Accdental Hypotherma; Ch 9 mmerson nto cold,vater BOP gudelnes' 28

31 ""-c...,..,..., NQ.37B P.35 - body weght; or evdence of dehydraton sgnfcant malnutrton and requ1res correctve acton Shaekngn 48 hours stfudard; Prolonged standng lkely ere gudelnes; nprght sttllg longer perods to nduce dependent experence wth. or horzontal requre medcal edema, 'ncrease rsk for 20+ detanees poston montorng DVT, cellults~ 'Vater donsng Cessaton upon ncreased h~at loss nwlderness evdence of promoted by Ctlntact wth Medcne" 4th Ed., hypotherma; water below 35 C; death Ch 6. - Accdental ambent can result from prolonged Hypotherma; Ch 9 temperature Le. 6 hour) exposure to mmerson nto mnmum of 64 F j 15 C water, 2 hr5 at 10 C, "cold water; 18 C; potable,vater 1 hr at 5 C; hypothemra Transport Canada, SO\ll'ce c~ be nduced n 30 fsunrval n Cold mnutes wth' 5 C 141 F \Vaters~', PRBAL \vater, 45 llnutes wth 10 Operatng C 54 F water} and 60 nsttllctods mnutes \yth 15 C / 59 F \vater mmerson. mmerson at ) temperatures below 25 C / 77 F wll eventually be fatal over lme. Sleep 48 hours for Perods of sleep etc Gudelnes";. deprvaton deprvaton of 90+ hours Home, J. Why \\]e have been shown to be safe and wthout long term sequellae n large groups, anq 200+ hours n ndvduals; requred recuperatve perod undefned. Note 0.5 C " drop n body temperature: whch may mpact use of water. Sleep deprvaton does degrade cogntve performance, may nduce vsual dsturbances may. reduce mmune competence acutely. Sleep NfNDSNH web ste 29 c"

32 _ --...,....t ) NO. 370 P.36.) Attenton grasp Facal hold Abdomtal sla.p Stress postons \Vallng Cramped confnement \Vaterboard Correct technque; no pruxstng njury lkely to be aggravated Correct teclurque; no preexstng njury lkely to be aggravated Correct technque;. no preexstng njury lkely to be aggra"l1ted Correct technque; no preexstng njury lkely to be ~ggravated Correct tcqbnque; no preexstng njury lkely to be aggra-vated Correct technque; no preexstng njury lkely to be aggravated Correct technque; no preexstng njury lkely to be aggravated At«~nt1)n to rsks of mmoblzaton, noludng DVT, and claustrophoba; ensure adequate ar flovl) ambent temperature Rsks nclude dro\vrung or Correct tecllnque; no preexstng. near drownng;. njmy lke! hypotherma from \varer exposure; aspraton pneumona, laryngospasm, PREAL Operatng nstructons PREAL Operatng nstructons O~1S Gudelnes; capablty mmedately at hand; potable water source 30

33 P.37 c. ) 31

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35 -'-'. '-'UJoJ "t',:u:.n 'J NO. 370 P.39, t ) 33