Physicians speak out on prisoner force-feeding

Doctor participation in the practice is wrong, say the AMA and other physician groups. The Defense Dept. says it is saving lives.

By Kevin B. O’Reilly — Posted April 3, 2006

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Reports in February that military doctors have force-fed hunger-striking detainees at Guantanamo Bay prompted the AMA and other physician groups to condemn physician participation in a practice they said violates a competent patient's right to refuse medical treatment. Military officials said the practice was humane and intended only to safeguard the life and health of detainees.

In August 2005, 75 of the nearly 500 detainees went on a hunger strike, said a Guantanamo Bay spokesman. That figure jumped to a high of 131 around the anniversary of the 9/11 terrorist attacks. By press time, that number had shrunk to six, as officials concerned that detainees might starve themselves resorted to restraining detainees to prevent them from resisting the administration of artificial nutrition.

In an editorial distributed to various news outlets, Duane M. Cady, MD, chair of the AMA's Board of Trustees, wrote that the AMA endorses the World Medical Assn.'s Declaration of Tokyo guidelines for physicians concerning the humane treatment of prisoners. Dr. Cady wrote that the declaration states that " '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 AMA has met with the Dept. of Defense over the past year "to voice our concerns, provide them with relevant policies and offer our expertise with the goal of ensuring that U.S. policies on detainee treatment comport with ethical standards of medicine. ... Our physician colleagues in the military, many of whom are placed in difficult, sometimes dangerous situations, deserve nothing less," Dr. Cady wrote.

Meanwhile, a U.N. report issued in February after an 18-month investigation said that if detainees' charges that insertion and removal of feeding tubes caused bleeding, vomiting and intense pain are true, "some of the methods used to force-feed definitely amounted to torture."

The AMA has policy opposing torture and physician participation in torture or any cruel, inhuman or degrading treatment of prisoners. The AMA House of Delegates has asked the Council on Ethical and Judicial Affairs to develop clear guidelines for physician participation in prisoner and detainee interrogations. CEJA is expected to report back at the AMA Annual Meeting in June.

Reports of physician involvement in force-feeding is gaining physicians' attention around the world.

A letter in the March 11 issue of The Lancet and signed by 255 doctors, mostly British, also objected to force-feeding. "Fundamental to doctors' responsibilities in attending a hunger strike is the recognition that prisoners have a right to refuse treatment," said the letter, whose lead signers included Holly G. Atkinson, MD, head of Massachusetts-based Physicians for Human Rights, and Dr. John Kalk, a British physician who in the 1980s worked in South Africa and refused the apartheid government's request to force-feed hunger-striking prisoners.

The U.S. government defends its policy. "We're trying to preserve life," said Defense Dept. spokeswoman Cynthia Smith.

Three of the six remaining hunger-strikers are being enterally fed, according to Lt. Col. Jeremy Martin, Guantanamo Bay's public affairs director. The detainees are "counseled on the potential health hazards associated with prolonged hunger strike by highly qualified medical doctors," Martin said in an e-mail. "A restraint system to aid detainee feeding" is employed "when required," he added.

"The feeding process for hunger-striking detainees is administered by doctors or registered nurses and is conducted in a humane manner for the care of the detainee as well as the protection of the guard force and medical personnel," Martin said.

As for charges that feeding tubes were applied in an abusive manner, Martin said al Qaeda trains members to falsely claim torture to elicit sympathetic news coverage.

Former Guantanamo Bay chief medical officer Capt. John S. Edmondson, MD, told a group of medical officials who visited last fall that military health professionals were "screened" before assignment to the detention facility "to ensure that they do not have ethical objections to assisted feeding," said a report in The New England Journal of Medicine. Federal prison physicians are allowed to order the force-feeding of hunger-striking inmates.

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