Unethical

07.21.13

Gitmo Prisoner Force-Feeding Violates Medical Ethics

The news that prisoners on a hunger strike at Guantánamo are being force-fed raises serious issues for the medical community, write Nuriel Moghavem and Marty Makary.

Guantánamo detainees on a hunger strike are now being strapped into chairs and gagged as doctors push a feeding tube through their noses into the backs of their throats and into their stomachs as often as twice a day. It’s a disturbing new practice, but one we must examine in full as we consider whether Guantánamo reflects American values.

Anyone who has had a nasogastric tube placed through their throat while awake knows why hospitalized patients often complain more about the tube than the pain of surgery. The gagging can be extreme, even when patients are relaxed and cooperating by swallowing repeatedly during the procedure. Resisting the tube during its insertion, as the unwilling detainees at Guantánamo do, elicits an exacerbated rapid cycle of gasping for air and gagging or vomiting.

Why is the U.S. government initiating this new round of forced gagging? It may be simply to save itself from the potential embarrassment if a majority of detainees die on a principled hunger strike.

Guantanamo detainees have resorted to desperate measures to call attention to what they and many others view as human-rights violations, including the disintegration of due process. A classified memo released in 2011 indicates that military officials were then aware that up to two thirds of inmates were, at best, “low level” threats and that nearly 20 percent were believed to be “innocent.” Nevertheless, 166 prisoners continue to be held, at least 106 of whom have participated in the hunger strike, being force-fed in what has been described as a medical-ethics-free zone.

Despite new pleas by doctors’ groups, including the American Medical Association, to end this practice, this form of cruel and inhumane treatment has now prevailed at Guantánamo with minimal public attention. In fact, a recent report indicated that prison officials have actually stepped up their plans to tube-feed prisoners in an effort to break the strike. The efforts likely include the threat to detainees that if they do not eat, they will be gagged with a tube in their throat—a threat implied if not explicitly stated. Even as the Muslim holy month of Ramadan began last week, there has been no indication that the U.S. military intends to suspend forced-tube insertions despite a motion filed in federal court last week. The judge ruled that she could not stop the practice.

For generations, physicians have selflessly upheld the pillars of medical ethics; chief among them is patient autonomy. Ironically, patient-centeredness has become a leading goal area in modern American medicine, backed by government funding for a newly established Patient-Centered Outcomes Research Institute. It emphasizes tailoring medical treatments to a patient’s wishes. Our government’s actions in Guantánamo fly in the face of this enlightened notion that medical decisions should be made by the patients, in partnership with their physicians and designated loved ones. If American doctors forcibly tube-fed any other competent patient tied up against their will, the public outcry would be deafening.

The cruel practice of forced nasogastric tube gagging of tied-down persons who have never had a trial is not an American value.

Last week 30,000 U.S. prisoners (who had a trial) went on a hunger strike, and there has been no mention of restraining them so that nasograstric tubes could be forced into their noses twice a day. But this practice is occurring every day at Guantánamo. While the practice receives little attention in the U.S., it is gaining attention outside the U.S. and fanning a wild flame of hatred that ought to be shrinking.

Guantánamo military doctors are violating the medical principle to respect a patient’s wishes and their oath to do no harm. Inmates have reported that doctors and nurses involved in force-feeding no longer wear name tags, a telling sign that the doctors and nurses may feel that what they are doing violates their medical heritage.

By using medical interventions to gag patients against their will, military doctors have strayed from their admirable role, historically marked with a red cross on their helmet, a sign even an enemy respected in the battlefield. Worse, this current precedent by military doctors is a terrible example to our nation’s 80,000 medical students. Violations of basic medical ethics tarnish a trust in physicians that could have future implications in U.S. medicine and international relations.

Being a doctor is a tremendous responsibility that often comes with great rewards. The distinct authority of our great profession would be strengthened if these military doctors refuse to place nasogastric tubes into tied-down detainees.

If gagging detainees through waterboarding was justified in the name of keeping America safe, what is the justification for forced-tube gagging today?

The cruel practice of forced nasograstic-tube gagging of tied-down persons who have never had a trial is not an American value. The U.S. should end this new wave of gagging recently initiated at Guantánamo and put patient treatment decisions in the hands of clinicians who take seriously their oath to do harm.