Monday, August 13, 2007

Another Travesty at Guantanamo

A group of doctors have expressed outrage over the force-feeding of prisoners at the U.S. prison camp in Guantanamo Bay, Cuba. In commentary published in the Journal of the American Medical Association (JAMA), the physicians expressed concern that doctors were violating medical ethics at the behest of the military.
"In medicine, you can't force treatment on a person who doesn't give their voluntary informed consent," said Dr. Sondra Crosby of Boston University, one of the authors. "A military physician needs to be a physician first and a military officer second, in my opinion."
According to CNN, 20 of 23 detainees on a hunger strike were being forcibly fed by nasogastric tubes. The tubes (pictured above) are typically inserted into the nasal cavity and run down the esophagus, terminating just above the stomach. They are used routinely in hospitals to allow liquid feeds to be given to patients who cannot safely feed themselves (due to level of consciousness, mechanical swallowing difficulties etc.). How does the military prevent patients at Guantanamo from simply removing the tubes?
Last year, the military started strapping detainees in restraint chairs during tube feedings to prevent the prisoners from resisting or making themselves vomit.
This may be seen by some as a contentious issue, but in this country (and presumably in the US), the law is quite clear. Any patient who is deemed capable of understanding the consequences of their decision, has the right to refuse medical treatment of any kind - even if that treatment if life saving in nature. Presuming a patient is deemed competent to understand the issue, any physician who administers treatment to a patient against his or her will is guilty of assault, and can be prosecuted in that regard.
The inmates at Guantanamo may be prisoners (or "detainees"), but to their doctors they are patients just like anyone else, and should be accorded the same standard of care. Pressure from the military is no excuse for a breach in medical ethics.


David Hunter said...

Agreed, it seems hard to see how this is compatible with professional ethics, and in particular patient's rights to autonomy.

Red Canuck said...

David - I think it's a reflection of the general way in which the detainees at Guantanamo have been viewed by the military and their political masters. Specifically, that they represent some "special class" of prisoner, and are thus not necessarily entitled to due process, Geneva Convention rights, and now, medical autonomy. It's unfortunate to say the least.

s.b. said...

But we treat people who have attempted suicide all the time, which is what this is, so your arguement falls flat.

In fact, the two reasons a person can be treated against their will in Canada are danger to themselves or to others.

It's not against medical ethics at all. In fact, it is required by medical ethics in this country.

red canuck said...

But we treat people who have attempted suicide all the time, which is what this is, so your arguement falls flat.

S.B. - You are misunderstanding both the law, and it's application as it pertains to administering medical treatments.

The reason that we treat people who have attempted suicide is that very often, the suicide attempt is a manifestation of a psychiatric illness (depression, schizophrenia etc.). Such a diagnosis, once made by a psychiatrist or other medical professional permits us to initiate treatment even if it is against the will of the patient. In fact, it is within our discretion to involuntarily hospitalize people who have psychiatric illness and pose a viable threat to themselves or others.

The reason for this has to do with the notion of competency (which I discussed in my post). The idea being that if you have a significant psychiatric or dementing illness, the effect on your cognition may render it impossible for you to make an informed decision about medical treatment. For example, if a psychiatric illness caused you to believe that everyone around you was an alien and it was your duty to kill them all, we could administer treatment to you against your will if we believed you posed a threat AND because you would be deemed incapable of rationally refusing treatment as a result of your psychosis.

Competency is a complicated issue, but in general, if one is of sound mind and capable of clearly understanding the consequences of their decision, they are deemed competent to make such a decision.

According to the CNN article, no psychiatric assessment was made of the hunger strikers at Gitmo. So, assuming they are of sound mind and understand that fasting could result in serious medical injury or death, we as physicians have no right to impose our will (or the will of the military) onto their medical autonomy.

Any such action is most definitely a breach of medical ethics.

MD said...

Very good explanation Red Canuck. Treating a competent patient without his consent is definitely unethical, and I am pretty sure that in the United States it is also illegal. (I believe it is technically assault and battery, but would normally be dealt with as a civil matter through tort law instead). I suppose that by keeping the prisoners in the bizarre legal no-man's land of Guantanamo Bay, the US government managed to strip prisoners of any semblance of rights, but they still cannot absolve physicians of professional responsibilites.

Red Canuck said...

MD - Yes, and I think that is the point being made by Dr. Crosby in the JAMA article. The Gitmo doctors are likely officers in the US army as well, and therefore have superiors to whom they must answer. But they are first and foremost physicians, and they should honour the oath they have taken regardless of the legal/political status of their patients.

Aurelia said...

RC, do you ever read

The moderator and several of the main bloggers are over the top anti-single payer medical care, but if you ignore their rabid ravings, there are a heck of a lot of Docs with blogs. Including a few Canadians.

Red Canuck said...


No, I hadn't even heard of it! Thanks for the link...I will check it out.

If it's infested with rabid privateers, as you suggest, I may not last long there!

AB said...

Was Private Lyndie England involved in any way???

Red Canuck said...


LOL! No, sadly not. Her randomized controlled trial entitled "Testicular Electrocution as Specialized Therapy for Enemy Strikers" (TESTES) was a failure. Turns out hunger strikers preferred placebo to testicular electrocution. Too bad for Lyndie!

Bowler said...

Off Topic, but that Levitrol video is hilarious!

Red Canuck said...


It's courtesy of the good people at MAD TV.

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