A very complicated ethical debate has arisen from the mess that is the Guantánamo Bay detention camp.
About 100 men are in the midst of a life-threatening hunger strike to bring world attention to their plight. In response, the U.S. has sent 40 medical personnel to “force feed” the prisoners sufficient calories to prevent their starving to death—and with the action surely has brought the prisoners a large amount of global attention.
Leaving aside for moment the substantial legal, moral, and political issue at hand, some might wonder just how a person can be force fed. Actually the procedure is pretty basic and something done all the time in hospitals, though for very different medical indications. In patients who are unable to eat, a feeding tube is often placed. This can be necessary after a stroke or other medical catastrophe. A parallel procedure is to use the same sort of tube to decompress or empty one’s stomach contents (aka “stomaching pumping”) either to ease the pain of an intestinal obstruction or else to rid the stomach of pills or other potentially toxic substances.
The hardware used in force feeding is very cheap and basic, though as with all medical equipment, there are ever more fancy versions. The procedure is this: after squirting a lubricant into one nostril, a two-foot long clear plastic tube of varying caliber, usually about as thick around as fat pencil, is snaked through the nose, down the back of the throat, and into the stomach. An X-ray is then performed to make certain the tube is placed correctly into the stomach or small intestine and not into the lung. Once confirmed, a liquid diet can be delivered and up to 2,000 calories a day provided—more than enough to keep a person alive.
During my training, I placed countless feeding tubes (and larger hoses to pump stomachs). Without question, it is the most painful procedure doctors routinely inflict on conscious patients. The nose—as anyone knows who ever has received a stinger from an errant baseball—has countless pain fibers. Some patients may scream and gasp as the tube is introduced; the tear ducts well up and overflow; the urge to sneeze or cough or vomit is often uncontrollable. A paper cup of water with a bent straw is placed before the frantic and miserable patient and all present implore him to Sip! Sip! in hopes of facilitating tube passage past the glottis and into the esophagus and stomach.
The procedure is, in a word, barbaric. And that’s when we are trying to be nice. (And yes, I know about freezing the tube and anesthetizing the back of the throat and using skinnier tubes and all the rest, but no one—repeat, NO ONE—who ever has received a feeding tube has been anything but wretched at the prospect of requiring it a second time.) Plus, though the worst of the discomfort ends with placement of the tube, its mere presence, often for days if not weeks, is distressing and distracting. Patients often become frightened of moving suddenly because of a concern the tube might slip out.
From the descriptions, 23 Guantánamo prisoners, similar to British women who went on a hunger strike a 100 years ago in order to receive the right to vote, are being wrestled into position to allow the procedure to be performed. Although no photos of the actual force feeding have surfaced, existing snapshots of chairs with belts to hold arms and legs have surfaced and resemble nothing so much as the electric chair.
The ethical end of the situation is, of course, vastly more complex than the awkward placement of a plastic tube. The Declaration of Tokyo, under the aegis of the World Medical Association has issued guidelines that directly address the issue and clearly state the physician should not place a feeding tube in a prisoner against his will:
“Where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially. The decision as to the capacity of the prisoner to form such a judgment should be confirmed by at least one other independent physician. The consequences of the refusal of nourishment shall be explained by the physician to the prisoner.”
The American Medical Association supports this view. U.S. and world courts, however, have not necessarily agreed with the World Medical Association and have on occasion ruled that feeding can be forced. The issue thus remains unsettled and unsettling.
In considering the issue, it is important to realize that force feeding inflicts two very different pains on a prisoner. One is the physical misery induced by the tube placement, which is nearly intolerable—but which, when given to standard patients for good medical reasons, ultimately justifies its use. The other pain is inflicted by doctors who willfully violate the wishes of a patient. That is a deeper and surely much more brutalizing pain.
In this debate individual doctors are stuck at a crossroads of unusual complexity. Sworn to alleviate pain and prevent death where possible, we also are sworn to respect the wishes of the individual. For us, there is no simple way out. Though sharing some similarities, the situation is distinct from respecting the wishes of a patient dying from an untreatable illness—starvation has a remedy.
It is facile to suggest that refusal to place the feeding tube, as suggested by groups including the AMA and the American Civil Liberties Union (of which I am a member), is the single conscionable approach. Just as the patient is an individual with rights that must be respected, so too is the doctor a human being with a personal moral code. I actually don’t know what I would do if I were one of the 40 medics dispatched to Guantánamo. But I do know I would not read a guideline or listen to the screeching admonishments from across the political spectrum. Perhaps the only lesson from the entire unhappy debacle is this: when a doctor is placed into a fraught situation as the agent of a political action, everyone loses.