A group of 263 physicians from seven different countries have added their voices to the chorus calling for more oversight at the Guantanamo Bay military prison in Cuba. The doctors argue that the force-feeding of prisoners on hunger strikes violates international declarations of medical ethics in a letter published in the March 11th issue of the British medical journal The Lancet.
“When a hunger striker chooses to go on hunger strike—when he or she is doing that as a mentally competent person—what is embodied in ethical guidelines is that their autonomy must be respected,” said Holly Atkinson, one of the letter’s co-authors and the president of Physicians for Human Rights. “Therefore, it is against medical ethics to force-feed a hunger striker.”
The ethical guidelines Atkinson referred to derive from the American Medical Association-approved Declarations of Tokyo and Malta, as well as World Medical Association standards and recommendations from Amnesty International.
The US government operates a military prison at Guantanamo Bay to house prisoners of war, who, it claims, are dangerous to national security, and therefore fall outside of ethical standards such as the Geneva Convention. About 500 prisoners have been detained without trial at Guantanamo for up to four years, and reports of human rights violations have trickled out in news stories and testimony from the prisoners and their lawyers. The US government contests the validity of these allegations.
On February 17th, the BBC reported that Kofi Annan, UN Secretary General, backed the UN’s recommendation that the Guantanamo Bay prisoners be released unless the US government put them all on trial.
Atkinson explained that the ethical issues at stake are patient autonomy and the loyalty of military physicians. The decision of a hunger striker to stop receiving nutrition is analogous to a patient refusing treatment for a fatal condition. In neither case should a doctor force medication or intervene in a manner against the patient’s will.
Moreover, she said, military physicians are particularly bound to always put the rights and best interests of their patients above their institutional ties.
“In this case, there’s a dual loyalty, in that we feel the conditions at Guantanamo are not set up for a physician to have what’s considered a counseling relationship with the patient: A relationship that’s based on trust and equal exchange of information,” she said.
Steven Miles, bioethicist from the University of Minnesota and former president of the American Association for Bioethics and Humanities, said that he “totally [agreed]” with the content of the Lancet letter.
“It’s a straight-up violation of medical ethics,” he said, adding later that force-feeding was just “another form of human rights abuse at Guantanamo.”
In a letter released by Physicians for Human Rights, John Edmonton, former commander of the hospital at Guantanamo, told David Nicholl, a co-author of the Lancet piece, that he was “justifying [his] actions by deferring to a higher military authority.” Edmonton claimed that at Guantanamo doctors were not force-feeding, but “providing nutritional supplementation on a voluntary basis to detainees who wish to protest their confinement by not taking oral nourishment.”
Atkinson and other signers of the letter are calling for an independent delegation of physicians to oversee ethical conditions at Guantanamo. Her secondary goal, she said, is to find a “remedy to the conditions of confinement.”
“One has to ask the question, ‘Why are these people on a hunger strike to begin with?’” she said. “Hunger strikers go on strike because often they feel that it is the only way, the last way, left to express any sort of autonomy, any sort of statement of self. And it’s ironic when the most powerful statement of self they can make is not to eat.”
Originally published March 12, 2006