Ethicists say military doctors shouldn't force-feed prisoners

Nov. 20, 2013: A U.S. Navy nurse stands next to a chair with restraints, used for force-feeding, and a tray displaying nutritional shakes, a tube for feeding through the nose, and lubricants, including a jar of olive oil, during a tour of the detainee hospital at Guantanamo Bay Naval Base in Cuba. (AP)

The U.S. military should rescind directives that authorize health professionals to participate in interrogations and force-feedings, some medical ethicists argue.

Responding to criticism from the medical community, the U.S. military recently cut back on use of psychologists to assist in interrogations or provide mental health care at facilities like the prison at Guantanamo Bay, Cuba.

The Department of Defense (DoD) should go further and prohibit military health personnel from participating in interrogations or force-feeding hunger strikers, according to Leonard Rubenstein, a public health and ethics researcher at Johns Hopkins University in Baltimore, and colleagues, writing in the journal PLoS Medicine.

"Policies barring participation in interrogation and force feeding are necessary to enable health professionals to fulfill ethical obligations adopted by the health professions to avoid inflicting harm, to be loyal to their patients, and to exercise independent professional judgment," Rubenstein said by email.

"Adherence to these ethical standards protects the rights of members of the military and detainees in military custody and also makes our military stronger by avoiding a gulf between military and civilian medicine that could impair recruiting of well qualified health professionals," Rubenstein added.

In their essay, Rubenstein and colleagues highlight recommendations from the Defense Health Board, a federal advisory committee to the Secretary of Defense that provides independent guidance on health matters.

A review last year by the board noted that military doctors often face "dual loyalty" conflicts between their ethical responsibilities and their obligations to the military. The board recommended that the DoD ensure its policies, guidelines and instructions let clinicians make the patient their top ethical priority, Rubenstein and colleagues note in their essay.

Mandatory pre-deployment ethics training and improvements to existing ethics courses recommended by the board might help achieve this goal, the essay's authors argue. Enhanced protections for military physicians whose commanders order them to breach professional ethics might also help, they say.

The essay notes that the board stopped short, however, of calling for an end to clinician involvement in force-feeding or tending to prisoners on hunger strikes or participation in interrogations.

Representatives of the Defense Health Agency and the Defense Health Board didn't respond to emails seeking comment.

Changes are necessary because participation in interrogations and force-feeding "violate(s) the basic principals of medical ethics including `do no harm' and beneficence," said Dr. Stephen Xenakis, a retired Army Brigadier General who wasn't involved in the essay.

"Military clinicians, particularly senior medical officers, justify participation in interrogations and force-feeding by asserting that the patient they're responsible for is the nation and government and not the individual they are supposed to be helping," Xenakis said by email. "This assertion, or rationalization, absolutely violates all principles of clinical medicine and healthcare."

Many health organizations - including the American Medical Association (AMA) - consider force-feeding a form of torture. The process involves supplying nutrients through a plastic feeding tube passed through the nose or mouth into the stomach, and has been used by the U.S. military in response to hunger strikes by detainees at the Guantanamo Bay prison.

The essay's authors say the need for new policies is also reinforced by a 2015 investigation showing that the DoD worked with the American Psychological Association (APA) to get approval for the participation of psychologists in interrogations. The APA changed its position, and the military recently curtailed use of psychologists in this role as a result, Rubenstein said.

"The order represents a recognition that Guantanamo commanders were demanding activities by psychologists incompatible with the ethics of the psychological profession," Rubenstein said. "That is not the end of the story regarding health professional participation in interrogation, though, as the directives that establish standards for health professionals throughout the military and which allow health professional participation in interrogation remain in place."