Military Doctors at the Guantanamo Bay detention facility regularly force-feed detainees who are trying to fight back in the only way they can - by going on hunger strikes. How can physicians, who take an oath to do no harm, deal with the gap between military orders and their own ethics?
A look at this....
In the New England Journal of Medicine this week, ethicist George J. Annas, J.D., M.P.H. writes about the situation of military physicians -
http://content.nejm.org/...
The use of the hunger strike is often the last resort of political prisoners who have no other way to make a statement. The Irish and the Vietnamese used this method to great effect to get attention paid to the situations in their country. In these cases, no force feeding was attempted until the patient was weak or comatose, and then as an attempt to keep the patient from dying; a nasogastric tube placed at the patient's bedside with no need for tying the patient down because the patient was already weak or unconscious.
At the Guantanamo Bay detention facility, as many as 80-100 hunger strikers are dealt with by force-feeding.
This force-feeding is apparently a uniquely 21st century Bushian procedure, because it is performed on men who are fully conscious and have to be placed in a special restraint chair that holds their arms and legs in restraints, and where the "patient" is often left to soil himself as further humiliation. The gastric tube is inserted, and close to a liter of liquid food is instilled into their stomachs several times a day - and it is military doctors who do these procedures.
In other days, this form of true "force" feeding was considered torture, as in the case of Soviet Victor Bukosvky who was force fed via nasogastric tube and reported as torture by the Council on Bioethics.
For military doctors stationed at Guantanamo, they are faced with the dilemma of following the orders of a superior officer and following the Hippocratic oath. Surely restraining conscious patients and performing a painful and humiliating procedure three or four times a day goes against the grain of "First, do no harm".
Everything medical is documented; the torture procedure of force feeding has its own medical boilerplate: "...the detainee refuses to eat in spite of advisement that hunger striking is deleterious to his health..." which every medical type will recognise as typical Cover Your Ass verbiage; only this verbiage is cynical excuse for torture.
The Guantanamo hunger strikers are particularly desparate - there is no way for them to be heard even with this most desparate of attempts. The more they starve, the more they are fed, and their last desparate efforts to speak only lead to more humiliation and pain.
What, then, is a doctor to do? Should the military doctors disobey a direct order and potentially ruin their career or worse? The DoD has tried to bridge this chasm of ethics and morality by rationalizing that force-feeding is in the best interest of the patients, and it is done in accordance with regulations issued by the DoJ's Bureau of Prisons. That supposedly makes it all better?
Other countries have addressed hunger strikers in a much more humane manner. The Royal Dutch Medical Association drafted a response to hunger strikes by Vietnamese asylum seekers that suggested the hunger strikers have access to "a doctor of confidence" who will act as their physician and keep them fully informed of the medical consequences of their hunger strike but also follow their wishes of nontreatment should they become incompetent or comatose, much like an "advance directive" is done. The US take suce a position for desparate non-white-"terrorists"? Never!
Again, the dilemma for the military doctor. I often wonder if the average young MD in the service ever had the idea that they may be required to torture patients.
Dr. Assan concludes his article with an optimistic (if unrealistic) statement that the military physician should be obligated to disobey an unlawful order - and the option to disobey an order that goes against medical ethics.
I try to put myself in the other guy's shoes..and when I thought about if I were the physician at Gitmo and was being ordered to push an NG tube down some poor fellow's nose....and the only recourse I can think of is "Can I swim 90 miles to Florida?"