RICHMOND — John Hagmann, a 59-year-old doctor accused of sexually assaulting and performing gruesome experiments on his trainees, had his medical license revoked Friday at a misconduct hearing of the Virginia Board of Medicine.
"Let it be noted that it was unanimous," misconduct panel chairman Kevin O'Connor said. "I'd like to thank the courageous medical students who came forward in this case."
Hagmann never showed up to the hearing, which came as no surprise to the Board. "I was informed twice last week by his counsel that Dr. Hagmann intended not to attend," Virginia Senior Assistant Attorney General Frank Pedrotty said at the beginning of the day's proceedings.
This was confirmed by Hagmann's attorney, Ramon Rodriguez, who said that Hagmann is out of the country and requested more time to prepare for the hearing.
"All Dr. Hagmann sought was a fair hearing of the facts where he could be present to answer the Board's questions, provide witnesses and defend himself," Rodriguez told BuzzFeed News by email. Rodriguez also said that Hagmann "intends to appeal what appears to be a clear violation of his constitutional right to due process."
Hagmann's license was suspended in March, two years after an anonymous student first reported his abusive behavior to the Uniformed Services University, the military school where Hagmann often conducted trainings.
Witnesses testified to a panel of nine doctors that Hagmann gave students dangerous drugs while they were inebriated, and performed unnecessary penile nerve blocks and rectal exams on them. Hagmann also allegedly asked students to perform rectal exams on himself, among other procedures that raised alarm on the panel.
"Everything was just so abhorrent and abnormal," said John Prescott of the Association of American Medical Colleges, who testified at the hearing as an expert on medical training. "In a combat situation, there's no need for a penile block, ever."
The hearing followed a report from the Virginia Board of Medicine, which was released in March and discovered by PETA in May. The report details how Hagmann had abused his power since at least 2012.
"The evidence was so overwhelming and bizarre that it was almost shocking to the conscience of a prosecutor who has been doing this for 26 years," Pedrotty said in his final argument. "He represented a real and present danger to the health of his patients."
It's unclear whether Hagmann will face criminal charges, Pedrotty told BuzzFeed News. He added that it's "unlikely" because in a criminal case Hagmann's students would be regarded as volunteers.
Witnesses testified Friday that they were subjected to Hagmann’s cruel and inexplicable experiments.
An Army Special Forces medic sergeant identified as "Patient C" detailed what happened to him while taking one of Hagmann's courses in Colorado.
Hagmann allegedly left the metal tip of a lidocaine infusion device in Patient C's chest, then had to remove it mechanically from his breast bone without sufficient anesthesia to forestall "extraordinary" pain. According to Patient C, Hagmann disparaged the suturing skills of Special Forces medics and walked away saying he was disgusted by a bad sewing job.
"When we look at all of these things, we see a lot of problems all across the board," said panel chairman O'Connor after Patient C's testimony. "The themes we keep coming back to are coercion, isolation and predation," he said later in the hearing.
"I am shocked as we all are," said panel member Maxine Lee, in response to testimony from another medical student, "Patient A," who said that Hagmann had repeatedly catheterized him.
Patient A also testified that Hagmann had performed a long rectal exam on him, and then said he realized he had "violated" the student and offered to let the student similarly examine him, in return.
An Army Captain who testified as "Individual E" by phone, said that during one of Hagmann's courses, the handle of a medical device broke off while it was attached to her shin bone and had to be removed with pliers, under a procedure conducted with only a local anesthetic. "I started crying," she said. "It was very painful."
In July 2013, at a DMI training in a warehouse in Partlow, Virginia, Hagmann drank beer with a man, "Patient B." This man then performed a penile and rectal examination on Hagmann, who videotaped it.
Patient B testified that he also allowed Hagmann to examine, manipulate, and photograph his penis. Hagmann was apparently interested in Patient B's penis because he wanted to know "the effect his uncircumcised penis had on masturbation and sexual intercourse," according to the Board's earlier report. Hagmann also took photos of the student's foreskin in "various stages of manipulation," saying the pictures were a "training tool."
That same month, at DMI's 20-acre facility in Pink Hill, North Carolina, Hagmann allegedly forced students to take between five and eight shots of liquor in 20 to 30 minutes, then injected a few of them with the dissociative drug ketamine. He then encouraged drunk students to perform nerve blocks on the penises of classmates who had been given ketamine, according to the report.
At the hearing, Pedrotty said that repeated attempts were made to get Hagmann's response to these complaints. Hagmann has not returned phone or email requests from BuzzFeed News.
Army Colonel Neil Page, who investigated the charges for USU in 2014, said that Hagmann hadn't denied that any of the procedures occurred, but characterized them as standard combat medicine education.
Hagmann’s company, Deployment Medicine International (DMI), has taken $10.5 million in taxpayer dollars to run classes on combat medicine for members of the military.
"Everything we do is oriented towards saving lives in a theatre of war," reads a DMI brochure. "DMI is the most experienced and professional corporation in this genre of medicine."
This blog post from 2012 shows photographs of Hagmann carrying out medical procedures on students in the U.K., sometimes without gloves.
DMI has been awarded almost $700,000 in Department of Defense contracts since the Navy claims it first learned about Hagmann's gross ethical misconduct in July 2013, including a $343,800 contract from the Navy a week after a student came forward with allegations of abuse. Hagmann was suspended from receiving defense contracts last week.
On Wednesday, Reuters reported that several high-ranking military officials have known about Hagmann's disturbing teaching methods since at least 2005. In email exchanges with Reuters, Hagmann wrote: "In 25 years no one has ever been harmed. What military training — or even most sports — can report that?"
U.S. Army Colonel Neil Page, who led a USU investigation into Hagmann in 2014, testified that Hagmann had retired from the university in 2000 under a dark cloud after getting unprofessional conduct job ratings.
A one-time pioneer in combat resuscitation medicine, Hagmann returned to teaching at USU in 2012 on the strength of his reputation and the turnover of leadership at the school, Page said, producing "amnesia" about his questionable activities.
On July 24, 2013, a USU student reported troubling behavior from Hagmann, at which point the university suspended its relationship with the company, according to USU spokesperson Sharon Holland.
The school notified the Naval Criminal Investigative Service five days later, she added, then contacted the Defense Criminal Investigative Service within 48 hours. A Defense Criminal Investigative Service representative declined to confirm or deny the existence of an investigation to BuzzFeed News.
The university conducted a "comprehensive internal investigation," Holland told BuzzFeed News by email. That was completed in December 2013. But the report wasn't sent to the Virginia Board of Medicine until February 25, 2014. It then took more than a year for the Virginia Board of Medicine to temporarily revoke Hagmann's license.
The original tip to Reuters came from animal rights group PETA.
Military medic trainings sometimes use pigs and other live animals to teach trainees how to treat injuries such as bullet or stab wounds in the field.
PETA had been tracking DMI since 2013, when a student of one of the live animal training classes sent the organization a video of the treatment of animals.
In the video, a student asks an instructor with his face blurred whether the pigs could be replaced by a mannequin. The instructor, presumably an employee of DMI, responds "Hajjis could do it, that would be even better. But it's not politically correct, and we can't do that." Hajji is an honorific given to Muslims who have made the pilgrimage to Mecca. Some members of the military have adopted the word as a derogatory term for people from the Middle East.
Now that the investigation has been made public, PETA is suspicious of the way the Navy seems to have punted responsibility to the Virginia Board of Medicine.
"It seems odd to me that an institution that prides itself on self-policing like the Department of Defense — if they did have information about the abuse of soldiers, why did they turn it over to a third party?" Justin Goodman, PETA's director of laboratory investigations, told BuzzFeed News.
Others have also called for an end to the use of animals in these trainings, including Hank Johnson, a Georgia Representative on the House Armed Services Committee.
Johnson first learned of Hagmann's exploits when a Reuters journalist contacted him for comment in the article that brought the story to the public eye, on June 8th.
After reviewing the case and discovering DMI had its eligibility for federal contracts renewed in May 2015, Johnson sent a letter to Secretary of Defense Ashton Carter asking for a detailed investigation into the allegations.
In addition to the animal issue, Johnson worries about using contractors for such important and sensitive courses. "We definitely need to always ask the question, why are we contracting out that training capacity?" Johnson told BuzzFeed News.
Military contractors may lack appropriate ethical oversight.
When it comes to contractors, "you're not being directly monitored, and to the extent there is monitoring it's probably paperwork compliance," Jonathan Moreno, a bioethicist at University of Pennsylvania who specializes in national security, told BuzzFeed News.
That said, even if there had been more oversight, Moreno said, "the rules are not designed for people who are nuts."
USU had not submitted Hagmann's course for ethical review before hiring his company. "Prior to the disclosure of the inappropriate procedures used, the DMI training courses were well regarded around the world for many years," Holland, the USU spokesperson, told BuzzFeed News by email.
This is one of several recent cases of military contractors grossly violating ethical standards due to lack of oversight.
In 2007, employees of Blackwater Security Consultants murdered 17 Iraqi civilians and injured 20 others in what is now known as the Nisour Square Massacre; four of the employees were later convicted of murder or manslaughter.
Likewise, the torture at Abu Ghraib prison was carried out by both service members and employees of CACI International and Titan Corporation. Though some soldiers faced consequences, including jail time and dishonorable discharge, no contractors were punished, and U.S. courts decided that the corporations had immunity from litigation.
Cases like these are making lawmakers take a close look at the use of contractors, which the military often uses as a way to reduce costs. According to a government report, more than 50% of the military is made up of private contractors.
This story has been updated with the Board's decision to revoke Hagmann's medical license.
This post has been updated with comments from Hagmann's attorney.
The Uniformed Services University educates students who will go on to work for the Department of Defense or the United States Public Health Service. An earlier version of this story referred to it as a Navy school.
Dan Vergano is a science reporter for BuzzFeed News and is based in Washington, DC.
Contact Dan Vergano at email@example.com.
Cat Ferguson is a writer based in Oakland, California. You can follow her on Twitter @biocuriosity or email her at firstname.lastname@example.org.
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