Guantanamo Bay: A Medical Ethics–free Zone? (New Eng Jour Med)

Really interesting Perspective piece from NEJM ~ pinto

Guantanamo Bay: A Medical Ethics–free Zone?

George J. Annas, J.D., M.P.H., Sondra S. Crosby, M.D., and Leonard H. Glantz, J.D.
N Engl J Med 2013; July 11, 2013

American physicians have not widely criticized medical policies at the Guantanamo Bay detainment camp that violate medical ethics. We believe they should. Actions violating medical ethics, taken on behalf of the government, devalue medical ethics for all physicians. The ongoing hunger strike at Guantanamo by as many as 100 of the 166 remaining prisoners presents a stark challenge to the U.S. Department of Defense (DOD) to resist the temptation to use military physicians to “break” the strike through force-feeding.

President Barack Obama has publicly commented on the hunger strike twice. On April 26, he said, “I don't want these individuals [on hunger strike] to die.” In a May 23 speech on terrorism, the President said, “Look at our current situation, where we are force-feeding detainees who are . . . on a hunger strike. . . . Is this who we are? . . . Is that the America we want to leave our children? Our sense of justice is stronger than that.” How should physicians respond? That force-feeding of mentally competent hunger strikers violates basic medical ethics principles is not in serious dispute. Similarly, the Constitution Project's bipartisan Task Force on Detainee Treatment concluded in April that “forced feeding of detainees [at Guantanamo] is a form of abuse that must end” and urged the government to “adopt standards of care, policies, and procedures regarding detainees engaged in hunger strikes that are in keeping with established medical professional ethical and care standards.”1 Nevertheless, the DOD has sent about 40 additional medical personnel to help force-feed the hunger strikers.

The ethics standard regarding physician involvement in hunger strikes was probably best articulated by the World Medical Association (WMA) in its Declaration of Malta on Hunger Strikers. Created after World War II, the WMA comprises medical societies from almost 100 countries. Despite its checkered history, its process, transparency, and composition give it credibility regarding international medical ethics, and its statement on hunger strikers is widely considered authoritative. The WMA's most familiar document is the Declaration of Helsinki — ethical guidelines for human-subjects research. The Declaration of Malta states that “Forcible feeding [of mentally competent hunger strikers] is never ethically acceptable. Even if intended to benefit, feeding accompanied by threats, coercion, force or use of physical restraints is a form of inhuman and degrading treatment.” The Declaration of Malta aims to set the same type of ethical norm as the Helsinki document. Physicians can no more ethically force-feed mentally competent hunger strikers than they can ethically conduct research on competent humans without informed consent.2

It's hardly revolutionary to state that physicians should act only in the best interests of their patients, with their patients' consent. At Guantanamo, this principle is seriously threatened because constant physician turnover makes continuity of care impossible. Detainee trust has also been irrevocably damaged by physicians' historical involvement in “enhanced interrogation,” as well as by the use of “restraint chairs” to break a 2006 mass hunger strike.3 Physicians may not ethically force-feed any competent person, but they must continue to provide beneficial medical care to consenting hunger strikers. That care could include not only treating specific medical conditions but also determining the mental competence of the strikers, determining whether there has been any coercion involved, and even determining whether the strikers want to accept voluntary feedings to continue their protest without becoming malnourished or risking death.4

http://www.nejm.org/doi/full/10.1056/NEJMp1306065?query=TOC