'Force feeding' at Guantanamo

nurse2033, MSN, RN · Jun 15, 2013

This is a classic ethical dilemma but I have to disagree with a point or two of yours. First of all, a prisoner is recognized to be a ward of the prison. Their legal status (whether convicted or not) does not matter. The prison has a legal mandate to take precautions to protect the life and safety of all prisoners. There are many people in US prisons and jail who are awaiting trial, for example, and have not been convicted. The fact that prisoners at Guantanamo may or may not have been charged does not matter regarding their medical treatment.

When you say "it is torture" do you mean the fact that they are receiving forced nutrition, or the manner in which it is being done? We feel that society has the responsibility to stop someone from killing themselves if it can be prevented. This is the rationale for the 72 hour mental health hold. We take away the autonomy of individuals who state they wish to die with full confidence that we are doing the right thing. We recognize that for most people this desire is temporary, and if they have time to think about or receive medical care, they will change their mind and feel differently. Since the prison is responsible for prisoner's safety, and the inmate has declared they wish to die, the prison has the right and the responsibility to intervene. If forced feeding was done for any reason other than medical care it would be an unnecessary medical procedure and therefore not be ethical.

As for the use of the NG tube, this is an unpleasant and painful procedure that I have done many times. I never thought it was torture any more than starting an IV, putting in a Foley, or having a tooth drilled is. Some medical procedures are are painful or uncomfortable. We all accept this as the price of doing business for an outcome of improved health.

The American Correctional Health Services Association (ACHSA) states that inmates do have the right to refuse care. But "involuntary treatment shall be reserved for emergency situations in which there is grave disability and immediate threat of danger to the inmate or others" (Schoenly & Knox, 2013). The situation of a hunger strike applies to this situation. Not only is the inmate in danger to themselves, but by inciting this behavior in others it threatens the safety of the group.

Especially because of the stress of incarceration, inmates may not be in a state of mind to fully comprehend the consequences of a hunger strike. Schoenly & Knox (2013) write that in the case of the hunger strike, "each correctional nurse must determine a course of action that is congruent with both personal and profession values in order to maintain professional integrity".

Military nurses are subject to nursing ethics, and also to the ethics and the values of their service. So a military nurse and a civilian nurse might make two different decisions, but both could be ethical. Nurses cannot be "left out of the picture" in medical decisions, no matter how difficult or uncomfortable they might be. In fact I would guess, that it is nurses who are doing the most to protect the inmate's dignity and reduce pain as much as possible.

Military nurses are not allowed to "refuse" to perform nursing care and procedures. They may refuse illegal orders, of course, but this does not apply in this situation. If a civilian nurse refused to perform a procedure they could lose their job. A military nurse could be charged with a crime. As an Air Force officer and nurse, I would not have joined if I did not have full confidence in my superiors to make legal and ethical choices.

I'm sure that none of these nurses are enjoying what they have to do. But I respect them for standing up and doing a difficult duty. As for your question of- what is this doing to our profession? By engaging in this debate I believe it makes our profession stronger. It also shows that ethics and theory are vital nursing skills. Medical ethics is a complex and challenging subject. The more we learn about it, the better we can apply it to our patient care.

Reference: Schoenly, L. & Knox, C.M. (2013) Essentials of Correctional Nursing, New York, NY: Springer

ckh23, BSN, RN · Jun 15, 2013

Is this torture? I would have to think so, especially since many of the prisoners being held there have not been convicted of a crime.
Every time the media covers this story, its always a nurse administering the feeding. What is this doing to the integrity of our profession?
If the military wishes to move forward with these practices, they should leave nurses out of the picture. And of course, military nurses should refuse to take part in such behavior.

I hope it was a hotdog wrapped in bacon.

IKnowYouRider · Jun 16, 2013

Unlike the poetic post below by ckh23, I can respect your answer even though I disagree on a few points.

First, I misspoke by stating that 'they haven't been convicted'. What I meant was that many have not been charged, which is even more appalling. But, anyway, that doesn't really relate too much to the subject at hand.

What I don't understand is that you seem to equate involuntarily detainment of mentally ill patients with prisoners at Guantanamo Bay. The only relevant similarity between these two populations is that they are both being held against their will. What really matters when speaking of patient autonomy is mental capacity. Clearly, patients in psychiatric units don’t have mental capacity, but I would argue that the prisoners of Guantanamo do.

How do we know they have mental capacity? Well, they make understandably sound arguments as to why they’re participating in their hunger strike, and their reasoning remains consistent on a day-to-day basis despite being persuaded to change their behavior. Due to their present mental capacity, I think a better comparison would be the hospice patient who decides to stop eating due to unresolved pain, hopelessness, etc. What does the medical profession do in this situation? Well, typically, we let them die. Therefore, I believe we should allow the prisoners at Guantanamo to do the same.

allnurses Guide · Jun 16, 2013

And you have been in the military how long? You have been to Guantanamo bay how many times? Don't judge those military nurses unless you have served in the military and/or have 1st hand knowledge. Just because these inmates haven't been tried in civilian court does not make them innocent.

amoLucia · Jun 16, 2013

To nurse2033 - a very informative and thought-provoking post.

Thank you for your service.

IKnowYouRider · Jun 16, 2013

@wtbcrna: You're right, only the nurses who have been to Guantanamo are able to question the ethical nature of force feeding prisoners. Also, civilians who have chose not to serve in the military should never question its actions because it's an infallible institution. Thanks for the update.

@nurse2033: Again, I appreciate your post. I wish more intelligent responses could have followed.

Edit: "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" (Declaration of Tokyo, 1975).

amoLucia · Jun 16, 2013

For the record - never have been military. Am RN almost 40 years. Your post has me thinking further.

You ask "is this torture"? Personally, I would say "NO". And this all hinges on the verb 'torture'. To me, "to torture" conveys an implied intention to do something harmful by the torturer to the victim for some reason/purpose that benefits the torturer. What benefit would the torturer be getting??? I don't see any in this case.

And the dictum "to do no harm" - what harm is being inflicted? I see benefit to the 'prisoner' as prevention of dehydration, malnutrition, electrolyte imbalance, and negative sequellae.

For whatever crime they've been incarcerated, they are prisoners to be protected. We protect prisoners in the general community population when jailed with protective custody, isolation, restraints, etc. We feed them, clothe them, shelter them. So points communicated by nuse2033 set very well with me.

I see no conflict with military nurses involved with the 'forced feedings'. Who do you suggest - civilian nurses? Non-medical civilians? Why differentiate?

Military nurses respond to the same ethical reasoning that all we other nurses answer - our own consciences and our professional licenses. And they respond to military command. They have enough to consider as they do their jobs and they have my greatest respect.

Finally, I do have concern with your Tokyo quote - I truly question the 'unimpaired and rational' decision-making status of those prisoners.

allnurses Guide · Jun 16, 2013

@wtbcrna: You're right, only the nurses who have been to Guantanamo are able to question the ethical nature of force feeding prisoners. Also, civilians who have chose not to serve in the military should never question its actions because it's an infallible institution. Thanks for the update.
@nurse2033: Again, I appreciate your post. I wish more intelligent responses could have followed.
Edit: "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" (Declaration of Tokyo, 1975).

And prisoners are force fed all the time. The point is you do not have common background to try to judge these nurses or the knowledge behind why these prisoners are there or what specific crime(s) are.

JoseQuinones · Jun 16, 2013

Military nurses are officers in their respective branches of the military. They join up with full knowledge that they will be required to obey orders from superiors, whether they agree with them or not. That is the nature of military service. If they object to obeying their superiors' orders, they have the option of either resigning their commission or facing a court martial for dereliction of duty and insubordination.

Rnaf · Jun 26, 2013

You might feel differently after you've deployed a couple of times and been shot at and rocketed constantly. These people want you dead for no other reason than you are American. Nothing like helping save the terrorists' lives after they tried to overrun the hospital in Bagram. Force feeding as torture....oh please

SoldierNurse22, BSN, RN · Jun 28, 2013

Military nurses are officers in their respective branches of the military. They join up with full knowledge that they will be required to obey orders from superiors, whether they agree with them or not. That is the nature of military service. If they object to obeying their superiors' orders, they have the option of either resigning their commission or facing a court martial for dereliction of duty and insubordination.

Legally, we are able to disobey an unlawful order. If someone felt iffy about this order, they could refuse on legal and moral grounds and very likely be safe doing so.

I personally don't know of anyone who would question it, however.