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Reader Comments on: Should Doctors Force-Feed Prisoners? See reader comments on this article and provide your own.
Readers are encouraged to respond to Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication as an actual Letter in MedGenMed via email: pblumen@stanford.edu
To the Editor,
Dr. Wynia's editorial[1] of October 5 addresses the problematic issue of force-feeding of prisoners. We all agree on the goal of compassionate treatment of prisoners, but there is a lack of unanimity in regard to force-feeding.
Physicians working in the field of correctional healthcare feel a strong ethical mandate to prevent inmate suicide. Voluntary starvation to the point of death is suicide, although Dr. Wynia implies that it is not.
It is important to recognize that the real-life situation in prisons presents an ethical framework that is very different from that in the free world. The prison environment is depressive, impairs judgment, negates free will, and may have a gradual erosive effect on mental competence. “Mentally competent” and “capable of forming an unimpaired and rational judgment” are terms whose meaning and validity are altered behind bars.
The American Correctional Health Services Association www.achsa.org adopted a position statement on Hunger Striking Prisoners in 1994. It acknowledges the ethical conflict between the obligation to preserve life and relieve suffering on the one hand, and the obligation to respect patient autonomy on the other. It advocates intensive counseling, thorough medical and psychiatric evaluation, and monitoring of weight loss and other parameters of deteriorating health. It also states that the prisoner should be informed that authorization will be requested to intervene with force-feeding when life is in danger.
The ethical situation is not as clear-cut as Dr. Wynia would have us believe. It is also not helpful to demonize the physicians who feel a greater obligation to preserve life than to honor a prisoner's wish to die for a cause. Ethical pronouncements by national and international medical organizations may not represent the thinking of those who are directly involved and doing their best to provide compassionate care.[1]
To the Editor,
Dr. Spencer provides a very thoughtful reply, which obviously comes from experience. It is impossible to convey the complexity of an issue such as the care of hunger strikers in a 300-word essay, and Dr. Spencer calls out some of the most difficult issues relating to the impairments of reason, competence, and autonomy that can affect any prisoner, and especially one refusing food.
First, with regard to common semantics, I agree that anyone who dies as a result of a choice he or she made may be called a “suicide.” However, there are important ethical and psychiatric distinctions between a person who is suicidal, ie, someone who wants to die and is acting to achieve that goal, and someone who is willing to die in pursuit of another goal. In short, the latter does not exhibit “suicidal ideation.” In medicine and especially in psychiatry, intent matters. Treating those who may be willing to die as though they want to die (even though death may be a common outcome) would cause one also to condemn as “suicidal” anyone doing something very dangerous. We sometimes hear that (“He must be suicidal to do that!”), but even such locutions tacitly acknowledge that, in fact, the actor is not suicidal. Parenthetically, whether we sympathize with the goal of the actor is not the issue; it is a matter of being clear about intent. In several ways, hunger strikers demonstrate on a daily basis that they do not want to die. If they sought death, they would refuse water, for example. Instead, typical hunger strikers seek a prolonged course, during which they can call attention to their cause and, they hope, negotiate an end to the strike. As a result, I continue to believe that it is medically misleading to call them suicidal.
That said, it is still possible that some prisoners at GTMO [Guantanamo] are, in fact, suicidal (ie, they seek death to escape their present circumstances or due to mental illness), and they see food refusal as their only possible means of suicide. On the one hand, at least some of the prisoners who have successfully hanged themselves at GTMO had previously been on hunger strikes. On the other hand, we have no evidence that the current strikers are actually suicidal, and at least 1 GTMO commander has said they are not. The bottom line is that no independent examinations of the current strikers have occurred, so we cannot know for certain.
This brings us to Dr. Spencer's mention of the ACHSA [American Correctional Health Services Association] standards. It would be a tremendous improvement to apply the ACHSA standards to the situation at GTMO, but at the moment this poses a number of difficulties. For instance, before involuntary feeding occurs under these standards, independent medical and psychiatric examinations occur and a court order is obtained. (“[T]he responsible medical authority must seek the consent of the court or a legally appointed guardian.[1]”). If prisoners in the United States are thought to be incompetent and to lack the mental capacity to choose to refuse food, this is a psychiatric and legal matter, which is clearly documented. Also, under ACHSA standards, involuntary feeding is acceptable only when “life is in danger.”
None of these is true at GTMO. As far as I know, there has been no claim, either medical or legal, that the prisoners undertaking hunger strikes at GTMO lack capacity. No independent examinations have taken place; neither independent judges nor doctors have reviewed the cases. Also, most important, the decision to initiate force-feeding is not made on a case-by-case basis by physicians considering medical criteria and whether life is at risk. At GTMO, force-feeding has apparently been applied as a blanket policy, implemented by military commanders for purposes of maintaining control and without regard for medical judgment. In other words, unlike in the US prison system, physicians at GTMO are not in charge of the medical decision to initiate involuntary feeding.
This last point is what worries me the most, especially in view of Dr. Spencer's reading that my prior editorial “demonized” prison physicians. I was hoping to convey the opposite, so I am saddened by this interpretation. Let me try again to explain – and hopefully I'll do it better this time: I believe that prison physicians do their best to make ethical decisions under difficult circumstances. It is the existence of such difficult circumstances that necessitates the development of codes of ethics. Ethical standards are created by agreement among the entire profession to facilitate and support ethical decision making. Without such codes, each physician would be left alone to figure out a proper course of action, with no guarantee of broader professional support for the choices they make. It is the special role of professional associations to support physicians in making ethical decisions, especially when the power structures in which we work press us to do otherwise.
So my greatest concern is that physicians caring for hunger strikers at GTMO may be under duress to act contrary to their ethics and their own sense of medically appropriate care. It is very important that the medical profession make it crystal clear that we stand ready to stand behind these physicians. If any of them are being compelled to act contrary to our shared codes of ethics, then it is the responsibility of the profession to stand together in their defense. I think they should be made aware of this support, lest the pressure to submit to a commander's order be impossible to withstand.
In summary, the physicians at GTMO need to know that they are not alone; in fact, they are in the majority if they see force-feeding of fully competent patients as contrary to basic medical ethics. Their professional associations will stand behind them if they choose to disobey any orders that contravene medical ethics.
