Pentagon warned against use of physicians in forced feeding

Revived efforts by President Obama to close the U.S. military prison at Guantanamo Bay in Cuba are bringing back debates about the practice of force-feeding prisoners and physician involvement in the procedure.

On April 30, Obama said the U.S. facility is not efficient or effective, or in the interest of national security, and that he is weighing new options for its closure. Congress blocked a move to shut the facility during his first term.

The declaration came amid a continued, mass hunger strike at the detention facility, where more than half of its 166 prisoners are refusing solid foods. The protests reportedly stem from years-long case delays and allegations of improper treatment by guards. The facility's policy has been to administer nutrition through a nasogastric tube to inmates who refuse food, restraining them if needed.

Some detainees are being force-fed at a feeding chair like this inside the Joint Medical Group at the U.S. military prison at Guantanamo Bay, Cuba. Photo by Army Sgt. Brian Godette

In an April 24 letter to Secretary of Defense Chuck Hagel, American Medical Association President Jeremy A. Lazarus, MD, reiterated the AMA's long-held position that physician participation in force-feeding violates the core ethical values of the medical profession.

“Allegations of ongoing forced feeding of detainees in U.S. custody, possibly with participation by physicians, continue to be brought to our attention,” Dr. Lazarus wrote. “Every competent patient has the right to refuse medical intervention, including life-sustaining interventions. … We urge you to ensure that this matter receives prompt and thorough attention and to address any situation in which a physician may be asked to violate the ethical standards of his or her profession.”

In an email, Lt. Col. Todd Breasseale, a Dept. of Defense spokesman, defended the enteral feeding, which he said was being applied to 24 of the 100 hunger strikers being tracked.

Defense Dept. policy is “to support the preservation of life by appropriate clinical means, in a humane manner, and in accordance with all applicable law and policy,” he wrote. The Defense Dept. “has well-established policies to protect both the detainees and the professional obligations of our medical care providers.”

Breasseale added that the department considers hunger strikes “a peaceful form of protest.”

Oversight deemed active participation

The Defense Dept.'s policy is inconsistent with the World Medical Assn.'s Declaration of Malta on Hunger Strikers and policies from a host of other national and international health organizations that condemn force-feeding at prisons, said Vincent Iacopino, MD, PhD, senior medical adviser for Physicians for Human Rights. Dr. Iacopino has done extensive research on alleged abuse of Guantanamo Bay detainees, examined inmates and testified in court on their behalf.

“Hunger strikes shouldn't be confused with the intent to commit suicide,” he said. “Hunger strikes are a form of protest, an attempt to shame detainee authorities into action by individuals who are desperate to have some control over their lives.”

At Guantanamo Bay, Dr. Iacopino said prison medical staff and officials generally confront inmates after nine missed meals and encourage them to eat. Prisoners also are asked to sign a consent form. If a detainee still refuses to eat, a physician decides whether he should be force-fed, he said. While nonphysician members of a medical staff may insert a feeding tube, a doctor must oversee the procedure, said Dr. Iacopino and other medical experts familiar with tubal feeding.

“Ultimately, any health professional has to act under the supervision of a physician,” said Arthur Derse, MD, director of medical and legal affairs at the Center for the Study of Bioethics at the Medical College of Wisconsin. “So somewhere a physician is necessary, because this is a medical procedure. The buck has to stop with a physician.”

Confrontational responses to hunger strikers often fuel the protests, Dr. Iacopino said.

“There's no therapeutic relationships between [detainees] and medical personnel and doctors,” he said. Mitigating hunger strikes mean “having a clinician who will respect your autonomy. That doesn't exist at Guantanamo.”

A hunger strike in Connecticut prison

Connecticut prisoner William Coleman challenged the state’s right to force-feed him in prison, but he lost both his case and an appeal. Most courts have upheld the rights of states to feed prisoners forcibly. Photo by AP / Wide World Photos

Military prisons are not the only places that hunger protests and force-feedings persist. Inmates in U.S. mainland prisons also strike regularly, although the majority of those protests are short-lived, said David McGuire, a staff attorney with the American Civil Liberties Union of Connecticut.

“Not many people have the will to go on a prolonged and potentially life-threatening protest,” he said.

At least one exception is William Coleman, a United Kingdom-born inmate of the Connecticut Dept. of Correction who has not eaten solid foods since 2007. Coleman, incarcerated at the MacDougall-Walker prison in Suffield, Conn., was convicted of sexually assaulting his estranged wife and sentenced to eight years in prison. He contends he was wrongly convicted and stopped eating to raise awareness of his plight, McGuire said. The ACLU represented Coleman in a court case against the prison after the inmate wrote to the group about being force-fed.

“Mr. Coleman testified about how degrading the procedures were and how painful they were,” McGuire said. “He was restrained, netting was put over his torso, and they forcibly inserted a tube into his nose and throat.”

A five-day bench trial in 2009 ended in the prison's favor. The judge ruled that the prison's right to protect the interests and safety of detainees outweighed Coleman's free-speech rights. In 2012, the Connecticut Supreme Court upheld the trial court's order. In general, most state courts have upheld the rights of prisons to feed strikers forcibly, McGuire said. No U.S. Supreme Court precedent exists on the legality of force-feeding prisoners.

The Connecticut Dept. of Correction declined to comment on Coleman's case. The prison system's policy calls for appropriate monitoring, assessment and treatment of inmates who abstain from food or fluids. The policy says prison medical leadership will inform the state attorney general's office of any hunger-striking inmate who may require a court order for involuntary feeding. The professional administering the nutrients must be videotaped explaining the procedure to the inmate and offering an opportunity to avoid it by agreeing to eat.

Despite serving his full sentence, Coleman remains in prison due to his refusal to register as a sex offender. His hunger protest is ongoing.