I previously weighed in on the controversy over force-feeding Guantanamo prisoners. When their health is seriously deteriorating–but not before–forced feeding is right. Here is part of what I said then:
Look at it this way: If an inmate hanged himself and the guards could save him, should they instead stand back and let him swing? Should doctors refuse to resuscitate a self-hanged prisoner because he clearly “wanted to die” or left a note refusing treatment? Or, if prisoners decided to bash their heads repeatedly into a wall as a means of protest, should officials be prevented from restraining them and doctors be ethically prohibited from stanching the bleeding and binding up their wounds? Of course not.
If that is true, it seems to me that the same rules apply to hunger strikes when they reach the point of health/life endangerment. And claiming that the strikers are not committing suicide, but willing to die to attain their political purpose–which would be political suicide–seems to me to be a distinction without a practical difference.
After my original post appeared, I was invited to debate the issue on BBC World Service. During that exchange, my doctor debate opponent said that Guantanamo doctors should actively assist hunger strikers by palliating their discomfort and otherwise help them keep the strike going without harming their health.
“That’s political activism, not medical ethics!,” I exploded. “Helping hunger strikers strike is not a doctor’s job.“
An article just published in the New England Journal of Medicine against forced feeding Guantanamo hunger strikers is also political, indeed, one aimed at influencing U.S. policy generally beyond the reaction to the hunger strike. From, “Guantanamo Bay: A Medical Ethics-free Zone?” by George J. Annas and others:
Guantanamo is not just going to fade away, and neither is the stain on medical ethics it represents. U.S. military physicians require help from their civilian counterparts to meet their ethical obligations and maintain professional ethics. In April the American Medical Association appropriately wrote the secretary of defense that “forced feeding of [competent] detainees violates core ethical values of the medical profession.” But more should be done. We believe that individual physicians and professional groups should use their political power to stop the force-feeding, primarily for the prisoners’ sake but also for that of their colleagues. They should approach congressional leaders, petition the DOD to rescind its 2006 instruction permitting force-feeding, and state clearly that no military physician should ever be required to violate medical ethics. We further believe that military physicians should refuse to participate in any act that unambiguously violates medical ethics.
Military physicians who refuse to follow orders that violate medical ethics should be actively and strongly supported. Professional organizations and medical licensing boards should make it clear that the military should not take disciplinary action against physicians for refusing to perform acts that violate medical ethics. If the military nonetheless disciplines physicians who refuse to violate ethical norms when ordered to do so, civilian physician organizations, future employers, and licensing boards should make it clear that military discipline action in this context will in no way prejudice the civilian standing of the affected physician.
Guantanamo has been described as a “legal black hole.” As it increasingly also becomes a medical ethics-free zone, we believe it’s time for the medical profession to take constructive political action to try to heal the damage and ensure that civilian and military physicians follow the same medical ethics principles.
I am aware that Annas’ opinion reflects the views of the bioethics and medical establishments. But urging military doctors to violate orders is no small thing–particularly since this isn’t a Mengele-type situation, where such refusal would be morally required. Indeed,the intervention is only necessary because of self-inflicted harm and the feeding seeks to prevent death and destruction of health, not cause it. In this sense, it is not the same thing at all as a cancer patient refusing chemotherapy.
Moreover, in this situation, Annas is urging that military doctors help the striking prisoners–at least some of whom are implacable enemies of the United States. This isn’t a case of tree sitters at Berkeley.
Here’s my bottom line:
- The significant policy questions some raise about Guantanamo Bay are legitimate.
- But Guantanamo inmates (and other prisoners generally) are not fully autonomous.
- Prison authorities are responsible for the wellbeing of those under their authority.
- Hunger striking is a legitimate political method of protest.
- A prison doctor should not use her or his professional skills to facilitate such a strike to make it more effective–nor impede it–until and unless the prisoner’s life or health is at significant risk.
- Forced feeding to prevent death is a legitimate medical act in the same way preventing a suicide attempter from dying is a legitimate medical act.
- Allowing a striking prisoner to die would be unethical.
- Prison authorities have the duty to maintain proper order within the facility, including, if necessary, force feeding hunger-striking prisoners in the most humane way practicable.
- If that requires physician participation, so be it.
In short, nothing Annas and his co-authors wrote changed my mind.