Ethical Issues in the Assessment of Terror Subjects

REVIEW

Elyse Platt,1 Philip J. Candilis2

1 Department of Psychiatry, Queen’s University School of Medicine, Kingston, Canada

2 Department of Psychiatry and Behavioral Sciences, George Washington University School of Medicine and Health Sciences, Saint Elizabeths Hospital, Washington D.C., U.S.A.

Cite: Platt, E., & Candilis, P. J. (In press). Ethical issues in the assessment of terror subjects. International Journal of Risk and Recovery. https://www.forensicpsychiatryinstitute.com/ethical-issues-in-the-assessment-of-terror-subjects/

The psychiatric evaluation of people who have committed acts of terrorism requires a unique sensitivity to cultural and political context. This is because terrorism has multiple definitions and can be used to silence political and ethnic minorities. Therefore, professional appraisals of risk and threat may require an ethics approach that intertwines individual and community factors, considering history and culture along-side individual risks. Narrative ethics using root cause and liberation theories may be one method to assess both contextual and personal contributions to terrorist behaviour, and provide a robust account of the cultural and contextual realities of terrorism.

Keywords: terrorism, psychiatric evaluation, forensic evaluation, risk assessment, threat assessment, ethics

Mental health professions are increasingly being called on to evaluate and explain terrorism. In the context of established mental health expertise in threat and risk assessment, this follows a comfortable and established logic. However, because of a range of definitions and cultural perspectives, identifying people who would commit acts of terror- ism and defining terrorism remain open questions in academia and international law (Kruglanski & Fishman, 2006; Laqueur, 1999).

While these limitations do not diminish the urgency of assessing radicalization, mitigation, and risk and protective factors, they create two substantial ethical problems. The first is that by asking mental health professionals to evaluate and treat people who commit acts of terrorism, the professionals run the risk of medicalizing political thought. Terrorism laws have been used to silence “dangerous” speech by nondominant groups (e.g., Saudi Arabia and China’s statutory definitions) (Human Rights Watch, 2017; Zhou, 2016). Secondly, if psychiatrists and other medical professionals stand apart from the political and historical implications of terrorism, they may be working outside their ethics. Medical ethics has come to recognize cross- cultural narratives, implicit bias, and the differential treatment of nondominant groups. To counter these potential pitfalls, it may be possible to draw from narrative ethics to conduct these fraught psychiatric evaluations while still taking considering the full range of explanatory social, political, and historical factors.

Defining Terrorism

A seminal difficulty in assessing terrorism is that terrorism has no agreed-upon definition (Kruglanski & Fishman, 2006; Laqueur, 1999). It often depends on the political and social context, generating dozens of definitions in law and scholar- ship. In general, terrorism is a political concept that involves violence or the threat of violence against a person or group to achieve a political, social, or religious goal (Hersh, 2006). It is this matter of political motivation — a motivation that invites multiple perspectives since the time of Aristotle’s polis — that creates the greatest uncertainty.

Even Nelson Mandela, who championed the rights of those oppressed by apartheid, was called a terrorist for targeting noncombatants, a charge levelled at George Washington, too, when he targeted British Loyalists and Indigenous people during the American Revolution (Hoock, 2018). Perspective matters to any analysis of social threats, and influences the resulting discussion of society’s response: Should it be cultural, clinical, or correctional? This problem of perspective is summarized well by Gerald Seymour (1975) in his novel Harry’s Game about “the troubles” in Northern Ireland. “One man’s terrorist is another man’s freedom fighter,” he writes. Indeed, while the British called captured Irish Republican Army (IRA) fighters terrorists, the IRA used the term prisoners of war (Caesar, 2017). Understanding a terrorist mind-set consequently requires an approach that considers context, culture, and perspective.

Ethical Issues

Political motivations matter, especially when psychiatrists are called to evaluate people who have committed acts of terrorism for signs of mental illness. In her paper, Psychiatry & Terrorism: Exploring the Unacceptable, Donatella Marazziti (2016) argued that psychiatrists ought to overcome their understandable “moral repugnance” for the accused person, focusing instead on sharp technical analysis of what motivates a person to commit such acts. The thinking behind such calls is a response to the long-recognized reaction that a person must be mentally unhinged to commit violence against an entire community. Similarly, in their editorial, Evil, Terrorism, and Psychiatry, Marazziti and Stahl (2018) argue that the psychiatrist should approach the evaluation by trying to understand the neurobiological mechanisms of aggression and what contexts allow aggression to become unharnessed from mainstream morality. They look to epigenetic mechanisms modulating stress response and emotional regulation as possible ways of understanding the neurobiology of extreme departures from social norms. They call on psychiatrists as scientists to overcome any repulsion they may feel about investigating terror and look to these biological underpinnings.

However, there is a risk in framing the psychiatrist’s role in a highly technical, biological way. It easily medicalizes a political position and is problematically reductionist. In fact, there is research indicating that most people who commit acts of terrorism are not mentally ill. Individuals acting within terrorist organizations generally display similar rates of mental illness as the general population (Al-Attar, 2020; Corner, et al., 2016; Prats, et al., 2019), and terrorist organizations are unlikely to recruit people with mental illness because of their presumed lack of discretion. Therefore, to look for diagnostic distinctions among people who commits acts of terrorism fails to explore distinctions outside the minority who may be mentally ill — certainly a primary obligation for anyone conducting a robust threat assessment.

Therefore, taking a purely neurobiological approach to violence fails to consider the rich political, social, and historical motivations at play. For example, in their narrative analysis of the case of Mohammad Rezaq, Stoddard and colleagues (2011), offered a detailed family history. Rezaq was a member of Abu Niddal who was tried in Washington, D.C., for hijacking EgyptAir Flight 648, killing two passengers, and shooting three others. The authors describe how Rezaq’s mother was forced from her Tel Aviv home in 1948 during the Arab-Israeli War. Again in 1967, when Rezaq was eight, his family was forced from their home on the West Bank and into a Jordanian refugee camp. In the camp, Rezaq was educated by the Palestinian Liberation Organization, which taught him that the only way to become a man was to join the revolution and regain the lands stolen from his family. The authors write, “When he skyjacked the EgyptAir plane, it was the proudest moment of his life. He was taking an action that would help regain his family lands” (Stoddard, et al., 2011).

We do not offer this detailed account of Rezaq’s history to excuse his actions, but to show that “explanations of terrorism at the level of individual psychology are insufficient in trying to under- stand why people become involved in terrorism” (Stoddard, et al., 2011). Asking a psychiatrist to explain Rezaq’s actions from a purely neurobiological viewpoint is reductionist because it fails to consider this rich perspective and ignores a context beyond a focused medical analysis. Solutions to intertwined individual and community problems are better found in narrative assessments of context, history, and culture.

Putting aside historical and political themes when evaluating people who have committed acts of terrorism places the work outside professional ethics. Medical professionals serve the social con- tract with a bio-psycho-socio-spiritual frame that exchanges professional autonomy and status for a recognizable mission and narrative. Falling outside that narrative has devastating consequences on the professionals and the society that privileges them. Indeed, the lessons of interrogating military detainees included loss of trust and collaboration domestically and abroad (Keram, 2006; McCarthy, 2013). Nations and professional organizations alike were appalled that clinicians served on the Behavioral Science Consultation Teams at the American detention camp in Guantanamo Bay, Cuba, advising interrogators on methods for increasing psychological distress among detainees. Medicine and psychiatry had already experienced the abuses of Soviet psychiatry and the participation of mental health professionals in American experiments during the Cold War. These departures from professionalism still cast a long shadow on any assessment of terror suspects.

The history of forensic psychiatry, the sub- specialty working at psychiatry’s intersection with the law, highlights the importance of the practitioner’s history, values, and judgments on security evaluations (Candilis, 2009). Forensic evaluations like risk and threat assessments can harm individuals, so the rules governing them had to be more stringent. There are stricter consent, more detailed confidentiality warnings, and the availability of legal counsel. Moreover, nondominant groups are known to be treated differently by the courts, so attention to culture and personal history matters. If psychiatrists are to evaluate people who commit acts of terrorism, it must be within an ethical framework that considers not only the historical perspective of the conflict but also the profession and society itself.

Role of Narrative Ethics

Narrative ethics provides a good starting point for understanding how a psychiatrist can take an approach that is sensitive to the social and historical context of the patient and the professional’s own values and biases. Exploration of narrative ethics, such as root cause and liberation theories, identifies socio-cultural, economic, and other conditions of oppression leading to terrorism (van Elk, 2017). In forensic psychiatry, there has been a move to augment the structure of professional ethics with narrative theories that consider the cultural and contextual realities of the judicial, correctional, and health care systems (Martinez & Candilis, 2020). After all, systems can be biased just like individuals. By placing the ethical focus on the individual’s narrative like Stoddard and colleagues (2011) did with Rezaq, narrative ethics considers the person’s social, historical, and political context, and looks for the tensions with powerful institutional values and biases.

Because terrorism is political by definition, these influences cannot be ignored. Candilis (2009) has written that a narrative understanding of professional ethics “allows a place for examination of personal values, of the evaluee’s narrative, and of a connection to a crime victim or community safety in general.” Using storytelling to describe the evaluee’s trajectory toward the forensic encounter covers personal and family history, oppressive experiences, interactions with the gov- ernment or religious groups, and other elements commonly connected to the behaviour of people who have committed acts of terrorism (Dhumad, et al., 2020). Moreover, it avoids provocative material (often remote sexual or substance history) that is irrelevant to the forensic question (e.g., is the individual at risk for future violence, are they responsible for their behaviour?).

Finally, taking a narrative approach to the psychiatric terror evaluation allows space for the mental health professional to examine the inter- section of their own moral and political perspectives compared with that of the evaluee. Consequently, a narrative allows the examiner to explore their own conscious and unconscious biases uncovering historical and systemic influences on themselves and their institutions to improve the quality of the assessment. In doing so, the psychiatrist self-reflectively works within their professional ethics not only to assess risk but also to unpack political motivations and social causes that may interfere with the assessment or create bias for the evaluator. Recent examples include not only terror definitions that identify dangerous thinking but also the differing treatment of White and Islamic defendants (Rondon, 2018; Sinnar, 2019).

Consequently, there are two overarching ethical implications for psychiatrists assessing people who have committed acts of terrorism. The first is that terrorism involves a political context, so psychiatrists may be at risk for medicalizing a political position. Second, if psychiatrists act outside of an ethics framework, they may become unmoored from their own and their profession’s moral and political values. Answering objective questions in the context of such subjectivity is not in keeping with current views of science and medicine — fields heavily influenced by a renewed focus on culture, perspective, and bias. Bias cannot be a novel and mysterious influence in a time of social determinants of care and racial determinants of judicial outcomes. Without a narrative frame that accounts for multiple perspectives and context, terror evaluations occur in a fantastical realm that presumes it contains all the influences on aggression. But these are not merely technical assessments that can ignore the perspectives and context of evaluator, evaluee, profession, and society.

Conflict of interest: none

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Corresponding author:

Dr. Philip J. Candilis, Department of Psychiatry and Behavioral Sciences, George Washington University School of Medicine and Health Sciences, Saint Elizabeths Hospital, Washington, D.C., U.S.A., philip.candilis@dc.gov

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