Guantanamo force feeding trial: the US is wrong to medicalize hunger strikingBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h669 (Published 11 February 2015) Cite this as: BMJ 2015;350:h669
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A recent report in this Journal recounts how South African physicians complied with the ethical requirements outlined in the WMA Declaration of Malta while caring for patients on hunger strikes. Their refusal to forcibly feed their patients is in stark contrast to the practices of military physicians and other health professionals have employed with hunger strikers at the Guantanamo Bay Prison (GTMO). Indeed, a recently released memorandum by a military lawyer on the legal authority to forcibly feed prisoners held at GTMO notes that while there is United States legal authority for force feeding the GTMO prisoners it also notes that force feeding mentally competent persons violates international law and “certain medical ethical standards.”
The US legal system has yet to embrace the ethical norms that should govern the practices of all physicians. Despite more than 10 years of controversy around hunger strikes at GTMO, Abu Wa’el Dhiab was the first to bring a federal court case to end his force-feeding. Although Judge Kessler concluded that Dhiab “failed to satisfy the ‘deliberate indifference’ standard of proof,” which is required to challenge a prisoner’s allegations of cruel and unusual punishment under the 8th amendment to the Constitution, the open hearing provided unprecedented transparency into the details of patient care and the practices of physicians at Guantanamo Bay (GTMO) caring for hunger strikers.
Two of us (SSC and SNX) conducted medical evaluations of Dhiab and testified as expert witnesses at his hearing. The following medical facts were disclosed in open court and, are available to the public (do not involve disclosures of private medical information).
Dhiab was mentally competent, and although malnourished, was in no imminent danger of death. He showed signs of right-sided paralysis, had severe pain, and was unable to walk. At the time of our visit, he had not been appropriately evaluated to determine the cause of his symptoms.
The primary obstacle to diagnosis and treatment of Dhiab was his distrust of the Guantanamo doctors. His records confirm that he frequently refused appropriate medical advice. He told us “the doctors are involved in punishment and their purpose is to torture.” Interviews with Mr. Dhiab, corroborated by the medical records, reveal that medical professionals were used as agents of the guard force to coerce him to stop his hunger strike. Doctors had refused Dhiab access to a wheelchair or crutches, forcing him to crawl on the floor and be forcibly extracted from his cell for feedings (instead of being transported voluntarily via wheelchair). Medical records document that Dhiab’s doctors refused to provide an appropriate mattress to ease his painful back, discontinued his back brace and even revoked access to socks and boxer shorts, which would generally not be a medical determination. These actions destroyed any possibility that a bona fide doctor-patient relationship could exist between Mr Dhiab and the GTMO physicians.
Despite his status as a hunger striker, Dhiab would accept nourishment voluntarily without the need for the harsh forcible feedings. We (SSC and SNX) ate with him. Dhiab was engaging in peaceful protest, was not suicidal, and had no desire to die. He wanted to be released and reunited with his family. The force-feedings ordered by the doctors, which included forcible extractions from his cell and the use of 5-point restraints in the feeding chair, were experienced as painful, humiliating and brutalizing. Unquestionably these procedures contributed to and exacerbated his pain and poor health.
While Judge Kessler did not grant the order Dhiab sought, she felt compelled to comment on his medical care;
The Court feels constrained to make certain comments about the Government's treatment of Mr. Dhiab. It is very hard to understand why the Government refused to give Mr. Dhiab access to the wheelchair and/or crutches that he needed in order to walk to the room for enteral feedings. Had that simple step been taken, numerous painful and humiliating forced cell extractions could have been avoided… By the same token, the Government refused Mr. Dhiab's request to provide him with an additional mattress. What could more reasonable than providing an additional mattress to a man with back pain so severe that he was given morphine to alleviate it?
Mr. Dhiab is clearly a very sick, depressed, and desperate man. It is hard for those of us in the Continental United States to fully understand his situation and the atmosphere at Guantanamo.
No matter if a prisoner is ‘evil incarnate’ or an innocent person who was unjustly imprisoned, medical professionals are ethically obligated to treat patients with respect, dignity, and humanity.
Organized medicine should treat these increasing disclosures of the misuse of medical knowledge and skills with the urgency it deserves. It is time to choose sides – it needs to be made clear one can be a tool of government mistreatment of people, or one can be a healer- but one cannot be both. Physicians must universally condemn Dhiab’s force feeding and other unethical medical treatment and urge the United States to learn from the South African example.
Kalk, WJ. Guantanamo force feeding trial: the US is wrong to medicalize hunger striking: BMJ 2015;350:h669
SC-SJA. Legal authority and policy for enteral feeding at JTF-GTMO" (Joint Task Force-Guantanamo) June 21, 2013
Dhiab v. Obama, 2014 U.S. Dist. LEXIS 157662
Competing interests: No competing interests