To Force-feed or Not?

Amid news that thousands of prisoners in the California penal system and at Guantanamo Bay detention center in Cuba are hunger striking, a debate is raging nationwide over whether doctors should force-feed prisoners against their will.

And though it has raised the ire of political groups and activists around the world, including Yasiin Bey, also known as rapper Mos Def, when the sensationalism and emotion is removed it still presents a disturbing ethical dilemma for doctors.

Is it ever OK to allow someone to die, especially if that person is in government custody?

Although a representative of the American Medical Association (AMA) declined to comment for this story, she did direct Healthline to an article published in the British Medical Journal last month by the AMA's immediate past president, Jeremy A. Lazarus. Although she said the article only represents the views of Lazarus, she added that it helps contribute to an understanding of the AMA's perspective.

“To put the physician’s dilemma more clearly, a detainee who refuses food challenges the physician to balance professional obligations: to respect the informed decisions of a competent patient and to serve the patient’s best (medical) interests,” Lazarus wrote. “The patient has the right to make decisions regarding the health care that is recommended by his or her physician. Accordingly, patients may accept or refuse any recommended medical treatment. The physician need not fully understand, or agree with, the patient’s decision but he or she must honor it.”

Further, Lazarus wrote that the AMA takes issue with the way in which prisoners are force-fed: A long tube is inserted through a nostril and down into the stomach while the patient is physically restrained. Bey demonstrates this in a video of himself undergoing the procedure, produced by UK human rights group Reprieve.

“Physicians should not be put in situations where they may be asked or ordered to violate the ethical standards of their profession,” Lazarus wrote. “The AMA continues to advocate for the humane treatment of detainees in keeping with the Code of Medical Ethics and the Geneva Conventions. As we noted in 2006, 'our physician colleagues in the military, many of whom are placed in difficult, sometimes dangerous situations, deserve nothing less.'”

A Moral Dilemma for Military Medics

George Annas, chair of the Department of Health Law, Bioethics, and Human Rights at the Boston University School of Public Health, has been a fierce critic of force-feeding prisoners. Still, he defends the military doctors who must make this choice. “They're not bad doctors,” he told Healthline. “They don't get the respect that they deserve.”

Annas was one of 19 medical professionals from across America who attended a symposium in April on the subject of prisoner hunger strikes at the Institute of Medicine in Washington, D.C. Also included in the group was a retired General, a top Pentagon official, and a representative of the Federal Bureau of Prisons.

The meeting was conducted under the Chatham House rule, which means the participants cannot be specifically identified. Quotes from individual members also cannot be revealed.

During the symposium, the members defined a hunger strike as something “generally done for a political purpose and someone outside the institution must usually know about it. Hunger strikers are not generally suicidal, but want something changed and are willing to die if they do not obtain all or at least part of what is initially requested.”

The participants concluded that there generally is not a reason to medically intervene until 30 to 40 days after the hunger strike begins.

Guidelines show that doctors should not focus on preventing death during the first 30 days, when a patient does not absolutely need to be fed. That time can be used to establish trust with the prisoner, according to a summary of the meeting.

In a statement to Healthline, an official with the U.S. Department of Defense defended the practice of force-feeding inmates by enteral feeding, which is most commonly performed by inserting a tube into the nose.

“It is the policy of the Department of Defense to protect the life and health of detainees by humane and appropriate clinical means, and in accordance with all applicable law and policy,” the statement read. “The Joint Task Force-Guantanamo medical staff continuously monitors and provides exemplary medical care to detainees at Guantanamo. The health and well-being of detainees is their primary mission, and they take this duty as seriously as they take their duty to provide medical treatment to U.S. service members or any other patient in their care.”

The statement noted that courts have upheld the practice of enteral feeding. “The enteral feeding procedure is medically sound, and is based on procedures performed not only in U.S. prisons, but in hospitals and nursing homes worldwide.”

Annas argues that in nursing homes, the practice is usually performed by surgically implanting a tube into the abdomen, which he says is more humane. “They [the Department of Defense] clearly know they need consent to do that.”

What Happens to the Body During a Hunger Strike?

Dr. Caroline Apovian, director of the Nutrition and Weight Management Center at the Boston Medical Center, said a human can survive for three to five months without eating. “We're the species, along with the orangutan, that can store the most fat.”

She explained that when the body burns fat, it experiences a process known as ketosis, where hunger is diminished and the brain continues to function. However, if ketosis lasts too long, organ damage can result.

Apovian noted that patients suffering from anorexia nervosa are often force-fed. The difference, she said, is that anorexia nervosa is a mental condition, and many of those sufferers are not competent to make their own medical decisions.

While the "refeeding" process can help people recover from self-starvation, sometimes a person who has gone without nutrients for long enough can actually die when nutrients are reintroduced into the body.

“It's an ethical dilemma, yes,” she said of force-feeding. “I know that a lot of people feel they [hunger strikers] should be left alone because they're politically making a statement. As a doctor it's very difficult to let that happen. We're supposed to be keeping people alive.”

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