The Optimal Policy Response to Hunger Strikes: Identifying the Line Between Medical Treatment and Torture

Since its establishment in 2002 as a facility to house individuals suspected of terrorism, the Guantanamo Bay (GB) detention center has been a subject of great controversy. Amid reports of torture and harsh interrogation techniques, policymakers have struggled to strike a balance between national security and respect for the human rights of the detainees. The Department of Defense (DOD) management of the 164 remaining inmates fell under further international scrutiny after the facility’s most recent hunger strike, a protest of alleged mistreatment and indefinite detention, began in February.

More than eight months later, the only thing keeping the nearly two dozen remaining hunger strikers alive is force-feeding. In an article published in Prehospital and Disaster Medicine, Harvard researchers Dougherty, Leaning, Greenough, and Burkle note the wide gulf between policymakers and physicians on the ethics of force-feeding and the consequences this may have for the integrity of the medical profession.

According to Dougherty et al., a hunger strike occurs when “a competent individual refuses food on a voluntary, informed basis and without suicidal intent, with all preconditions confirmed by an evaluating physician.” Should the strike persist without intervention, it leads to death by starvation or dehydration.

At GB, once a hunger striker has missed nine consecutive meals, the Base Commander orders medical personnel to physically restrain the inmate to a chair and weave a nasogastric tube through his nose and into his stomach, to deliver nutrients directly. Medical staff then supervise multiple two-hour feeding sessions each day.

Dougherty et al. point out that according to the World Medical Association’s (WMA) Declaration of Malta on Hunger Strikers, civilian physicians are urged to convey the medical risks involved in prolonged fasting, but are otherwise required to respect the patient’s desire to fast. On this basis, they argue that force-feeding prisoners on hunger strike violates the established medical code of ethics because it waives the requirement to obtain informed consent and performs an involuntary medical procedure on a mentally competent patient.

In contrast to the WMA’s position, government proponents contend that it is morally inconceivable not to force-feed the hunger strike participants. In 2013, US Secretary of Defense Chuck Hagel stated that the government has an “ethical responsibility to assure the health and well-being of every detainee and we’re certainly doing everything we can to do that.” The DOD’s revised 2013 Standard Operating Procedure: Medical Management of Detainees on Hunger Strike categorizes hunger strikes as suicide attempts and describes the duty of the medical unit as preventing death.

As Dougherty et al. point out, some medical researchers disagree, claiming that ‘‘[h]unger striking is a peaceful political activity to protest terms of detention or prison conditions; it is not a medical condition.’” They argue that force-feeding amounts to both a violation of autonomy and a form of cruel and unusual punishment, and at GB in particular it may be a way of suppressing legitimate political protests.

From within the military system, Dougherty et al. identify two institutional features that insulate the force-feeding policy from criticism: the DOD selection process for healthcare professionals, whereby only physicians willing to participate in force-feeding are recruited to work at GB, and the lack of legal recourse for physicians who prefer not to support the practice on ethical grounds. They advocate that, at a minimum, the law should protect the right of physicians with ethical objections to exercise independent judgment and refuse participation without consequences, in order to protect the integrity of the medical profession.

Much of the policy debate over force-feeding has occurred in the Courts. However, numerous administrative and legal challenges to the procedure have yielded few results: state medical boards often decline jurisdiction over military activities, and federal judges generally uphold force-feeding in light of the state’s interests in preserving life and maintaining prison order.

However rare, hunger strikes at correctional facilities are an influential political tool used by individuals with few alternative ways to communicate grievances. Despite vocal opposition from doctors and prisoners’ rights advocates, force-feeding continues to be the dominant policy response to hunger strikes at correctional facilities, including California’s Pelican Bay State Penitentiary in July 2013. The appropriate response to hunger strikes is a subject on which the policymakers who order force-feeding treatment and healthcare professionals charged with administering it remain far apart, to the possible detriment of all parties.

Feature Photo: cc/(jeshua.nace)