First, do no harm. It’s a commandment often incorrectly attributed to the Hippocratic oath yet it provides an ethical foundation for modern medicine. The American Medical Association’s principles of medical ethics begins, “A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.”
But what happens when a physician violates this ethical code? This is not a hypothetical question — it’s a transgression happening right now at the U.S. military detention camp at Guantánamo Bay Naval Base in Cuba. On November 1st, a group of more than 35 physicians, former military personnel and health experts sent President Obama a letter demanding that he end the practice of force-feeding hunger strikers at the prison. The letter’s signers, who include a retired Brigadier General and former U.S. Surgeon General, identified themselves as deeply invested in maintaining the principles of medical ethics. “We believe that the practice of force-feeding hunger strikers at Guantánamo Bay severely breaches those principles and undermines medical care at the detention center,” they write.
This wasn’t supposed to happen. President Obama made a campaign promise to close “Gitmo,” and on January 22, 2009, he issued an Executive Order, “Closure Of Guantanamo Detention Facilities.” The order promised that, “The detention facilities at Guantánamo for individuals covered by this order shall be closed as soon as practicable, and no later than 1 year from the date of this order.”
Four years later, the prison at Guantánamo Bay still houses 164 detainees. Only six of these prisoners face formal charges. According to the New York Times, intrusive searches of the detainees’ Korans were sometimes cited as the reason for the hunger strike that began earlier this year, “But both detainee lawyers and military officials agreed that the underlying cause of the protest was the growing despair of the inmates over whether they would ever go home alive.”
“Hunger strikes at Guantanamo are protests against legitimate grievances — torture, and years of indefinite detention without charge and without hope of release,” says physician Vincent Iacopino, senior medical advisor for Physicians for Human Rights.
“I went on a hunger strike for two years because no one would tell me why I was being imprisoned,” wrote Lakhdar Boumediene in 2012. Boumedine spent seven years detained at the Guantanamo Bay prison before being released on May 15, 2009.
In September, military leaders declared the most recent six month hunger strike “over,” but this Miami Herald data tracker shows that it hasn’t yet ceased entirely. Yesterday, 14 Guantanamo prisoners were force-fed.
We don’t know exactly who these 14 are, but the Miami Herald has identified 24 detainees known to have been subjected to forced-feeding — nearly all of whom have never been charged with any crime. At least 11 have been cleared for release, yet they’re still detained.
The military personnel carrying out the forced feeding aren’t just locking captives in a room with cookies and leaving them there until they’ve eaten all the crumbs. Instead, as shown in this haunting video produced by the Guardian and painfully re-enacted by rapper Yasiin Bey (known as Mos Def), a tube is forced down the prisoner’s nose and into the stomach.
An independent panel gathered by the Institute on Medicine as a Profession recently published a nearly 300 page report, “Ethics Abandoned: Medical Professionalism and Detainee Abuse in the ‘War on Terror,’” outlining the involvement of medical personnel in practices it deemed torture. The report says that, “Feedings in restraint chairs were generally administered daily as long as the hunger strike continued, in some cases for months or years. For some detainees, the use of restraint chairs and force-feeding was painful and constituted a violent assault; some have suffered long-term deleterious consequences as a result.”
The practice of force-feeding serves no medical purpose, and the task force concluded that “The practice is used as a punitive measure to induce prisoners to give up their protests.”
“When the Secretary of Defense said in 2003 that we’re going to ‘take the gloves off’ and that the Geneva Conventions do not apply to these prisoners and detainees, that changed the rules that military physicians and military officers had been living by and willing to fight for,” says Stephen Xenakis, a psychiatrist and retired U.S. Army Brigadier General who has interviewed nearly 50 detainees and reviewed their medical and intelligence files.
I met Dr. Xenakis last month at a conference on moral injury, where he told me, “Torture violates our humanity.” And it’s not just the humanity of the torture victim that’s violated — the perpetrator may suffer deep psychological injury as well.
But a military physician who doesn’t want to take part has “no options,” says Iacopino. “Forced feeding is compulsory in accordance with the 30 page Standard Operating Procedure manual.” Iacopino knows of no physician who has refused to force feed.
Iacopino told me that U.S. officials have justified forced feeding via three arguments — first, that the World Medical Association and American Medical Association ethical principles are not legal documents that the US must follow; second, that forced feeding is practiced in US prisons; and, third that the force feeding has a benevolent purpose — to prevent the hunger strikers from dying. But Iacopino says that forced feeding in American prisoners involves convicted criminals, while most Guantanamo prisoners have never been charged with any crime.
Hunger strikes are widespread among Palestinian detainees in Israel, and yet doctors there do not force-feed, says Len Rubenstein, director of the program on human rights and health in conflict at the Center for Public Health and Human Rights at Johns Hopkins University. In the last 12 months, something like 1,000 Palestinians have staged hunger strikes, and Rubenstein says that to his knowledge, none of them have starved to death. Hunger strikes are political protests, not suicide attempts, he says.
Military doctors face tremendous challenges building trust of their patients, says Xenakis. Detainees at Guantanamo recognize that prison doctors don’t have independence or autonomy when it comes to directing their medical care — “They’re subordinated to the command.” Furthermore, some of these detainees have been subjected to so-called “enhanced interrogation” where physicians participated. Why would a detainee trust any prison doctor after that?
On May 23 of this year, President Obama addressed the problem of Guantanamo Bay. “Imagine a future – ten years from now, or twenty years from now – when the United States of America is still holding people who have been charged with no crime on a piece of land that is not a part of our country. Look at the current situation, where we are force-feeding detainees who are holding a hunger strike. Is that who we are?”
Until President Obama uses his power as Commander in Chief to respect human rights and international medical ethics, the answer to his question, says Iacopino, “Is an emphatic yes.”
Image: The America I believe in would shut down Guantánamo Bay by Steve Rhodes.