1. Military Medical Ethics: Force Feeding; Clear as Mud? Walter J. Coyle, FACP Governor, Navy Chapter American College of Physicians

2. Objectives Review the definitions of hunger strike and hunger strikers. Review the dynamics and difficulties of caring for detainees and prisoners having a hunger strike. Understand the role of force feeding of detainees and prisoners having a hunger strike. Review the ethics of forced feeding including the statements of the World Medical Association and AMA on Medical Ethics and the Geneva Conventions. Review the DOD instructions for the care of detainees. Provide an ethical guideline for doctors caring for prisoners and detainees.

3. Cuba stays in the News Questions of legality at GTMO Medical complicity? Medical support of interrogations? Role of Medical in Forced Feeding

4. Most recent article N Engl J Med 355;13 September 28, 2006

5. NEJM articles N Engl J Med 352;20 May 19, 2005

6. Prominent Journals N Engl J Med 2006;353:6-8

7. What I do know about GTMO? Receiving top notch medical care Better care than prisoners in US Access to physicians including mental health Nutrition and appropriate medications Detainees receiving CRC and Barrett’screening (voluntary) Detainees receiving advanced cardiac evaluations and even catheterization

8. Medical Ethics in GTMO Last ACP, we reviewed the GENEVA conventions and the WMA / AMA ethics for prisoners and detainees. We reviewed the ethics of any physician involvement in interrogations or torture For the last two years there has been controversy around forced feeding and hunger strikes at GTMO

9. Medical Ethics at GTMO What is a hunger strike? Does that differ from a death fast? Why do individuals or groups enter a hunger strike?

10. Hunger Striker A mentally competent person who has indicated that he has decided to embark on a hunger strike and has refused to take food and/or liquids for a significant interval. WMA, Declaration of Malta, November 1991

11. Hunger Strike An action in which a person or persons with decision making capacity refuses to ingest vital nourishment until another party accedes to certain specified demands. J Med Ethics 2005; 31:169-172

12. Death Fast A person asserts that fasting will continue to death unless the aims of the strike are met. As in hunger strikes will usually still ingest water, salt, and B vitamins (especially B1 to prevent neural damage) J Med Ethics 2005; 31:169-172

13. Weapon of Last Resort Hunger strikers are using what means are left to them to effect change or draw public attention Most are NOT suicidal Most are competent Significant % have depression or PTSD

14. Dilemma of Balance Life Autonomy

15. Turkish Experience Collective Prison hunger strikes: 1996 Prisoners protesting harsh conditions – Beatings and isolation – Denied access to medical care From 1996-2003 – April 2001: 222 death fast; 569 hunger strikes, 153 prisoners hospitalized – By 2003, over 100 deaths J Med Ethics 2005;31:169-172

16. Turkish Government Response Government-employed physicians must preserve life – Included force feeding against strikers will The Government later threatened physicians with judicial action if they refused to force feed prisoners. J Med Ethics 2005;31:169-172

17. Turkish Medical Association Response The TMA stated it was unethical to treat hunger strikers against their will: violated the principle of informed consent. The TMA even stated the Association might investigate physicians who fed or treated strikers without their consent. Goes beyond the declarations by the WMA J Med Ethics 2005;31:169-172

18. Other Famous Hunger Strikes Political prisoners in the Gulag Archipelago – Cold war Irish Republican Army prisoners in Maze prison (1980s) Turkish prison strikes (1996-2003) Gandhi

19. Gandhi (1896-1960) Gandhi fasted/hunger struck over 14 times Never exceeded 21 days Was successful in achieving his agenda Powerful political tool BMJ 1997;315:829-830

20. Russian Dissenter They started feeding me forcibly through the nostril. By a rather thick rubber tube with a metal end on it…the procedure will be that 4 or 5 KGB agents will come to my cell, take me to a medical unit, put a straightjacket on me, tie me to a table, and holding me down…It’s painful like hell I must tell you…the tears will be filling your eyes and sort of streaming down because it’s so painful… Vladimir Bulovsky, President’s Council on Bioethics, 2003:218-9

21. Doctor-Patient Relationship Profoundly affected by a hunger strike Whether respecting the persons wishes or force feeding, you have acted (ethical or political) Physician must remain neutral and be above coercion. Must advise and maintain a relationship with the striking person J Med Ethics 2005;31:169-172

22. Military Medical Ethics Dual Loyalty – Medical Oath – Military Oath “State-employed” physicians – Occupational Health – Prisons Comrades in Arms National security Insert picture

23. DUAL LOYALTY “ When physicians have responsibilities and are accountable both to their patients and to a third party and when these responsibilities and accountabilities are incompatible,they find themselves in a situation of ‘dual loyalty ’.” WMA Ethics Manual, 2005

24. Four Physician Responsibilities Assess competency, informed decision – Advanced directives, assess wishes (did he/she want to die?) Decisions free of coercion: assess the persons freedom to choose – Coercion by religion, other prisoner Informed understanding of the medical risks of prolonged fasting. Physician must be willing to provide medical care and re-feeding if requested. J Med Ethics 2005;31:169-172

25. Ethical Dilemma in Hunger Strikes Is it ethical to force feed a competent hunger striker? Is it ethical to artificially provide nutrition when a patient becomes incompetent or unconscious? There is no absolute final authority on assessing the medical ethics of physicians who care for hunger strikers.

26. WMA guidelines on hunger strike Declaration of Tokyo 1975

27. WMA guidelines on hunger strike Declaration of Malta 1991

28. WMA guidelines on hunger strike Declaration of Malta 1991

29. AMA guidelines on hunger strike March 10, 2006

30. ACP guidelines on hunger strike: there are none, but… Physicians must not be a party to and must speak out against torture or other abuses of human rights. Participation by physicians in the execution of prisoners except to certify death is unethical. Under no circumstances is it ethical for a physician to be used as an instrument of government to weaken the physical or mental resistance of a human being, nor should a physician participate in or tolerate cruel or unusual punishment or disciplinary activities beyond those permitted by the United Nations Standard Minimum Rules for the Treatment of Prisoners (90). Ann Intern Med. 2005;142:560-582.

31. New DOD Guidelines “In general, health care will be provided with the consent of the detainee.” “Detention facility procedures for dealing with involuntary treatment may be necessary to prevent death or serious harm shall developed…”per “Title 28, Code of Federal Regulations, Part 549” DOD instruction 2310.08E, June 6,2006

32. New DOD Guidelines “4.7.1. In the case of a hunger strike, attempted suicide…medical treatment may be directed without the consent of the detainee to prevent death or serious harm. Such action must be based on medical determination that immediate treatment is necessary to prevent death and serious harm and must be approved by the commanding officer of the detention facility…” DOD instruction 2310.08E, June 6,2006

33. Assisted Feeding/Forced Feeding Military Health Care providers were “screened” for ethical objections per Commander at GTMO. Hunger strikers carefully monitored: – Wgt, BMI, labs, physical exams Instituted once deemed “medically necessary”. Assisted feeding chairs now used N Engl J Med 2005; 353:2529-2534

34. Assisted Feeding/Forced Feeding Detainees are not suicidal but are protesting confinement. Hunger strikers may not have autonomy or be able to make informed consent. DOD has decided to favor involuntary intervention in order to prevent deaths. N Engl J Med 2005; 353:2529-2534

35. Dilemma of Balance Life Autonomy

36. Forced Feeding: Legal perspective British Courts have ruled in favor of autonomy over forced feeding – IRA prisoners starved to death in 1981 US Courts have tended to favor forced feeding in US Federal Prisons. Detainees in general have not had habeus corpus ie.. there has been no legal ruling or appearance before a judge. N Engl J Med 2005; 353:2529-2534

37. Legal versus Ethical conflict: Capital Punishment Legal in the judicial system of the U.S. Unethical for physicians to participate according to state medical societies, the AMA, the ACP, the WMA Does not prevent state or federal directed execution – Physicians should NOT participate or risk reprimand or loss of licensure

38. Legal versus Ethical conflict: Forced Feeding The judicial system of the U.S. has not ruled on the legality of forced feeding at GTMO The courts have mandated that the Geneva conventions be applied to detainees. No state medical licensure board has revoked or reprimanded military physicians at this time. Hayden vs Rumsfeld, 2006

39. The core of obligations for all armed conflict Common Article 3 of Geneva Convention – Regarding treatment of Prisoners of War – “The following acts are and shall remain prohibited at any time and in any place whatsoever: Violence to life and person, in particular murder of all kinds Mutilation Cruel treatment and torture Outrages upon personal dignity –In particular, humiliating and degrading treatment”

40. Article 17 No physical or mental torture, nor any other form of coercion, may be inflicted on prisoners of war to secure from them information of any kind whatsoever Prisoners who refuse to answer questions may not be threatened, insulted, or exposed to any unpleasant or disadvantageous treatment of any kind. Geneva Conventions

41. Ethics and you The “correct” ethical decision can be unclear. As a physician, you cannot be ordered to violate your medical ethical decision. – Must be removed from the area – Be thoughtful, well read, make a good choice – Only exception: “Supreme Urgency” ie the ticking bomb scenario

42. Ethics and Clarity “The certainty of ethical opinion is directly proportional to the square of the distance from the site of combat.” Colonel Basil Pruitt, MC, USA

43. What can we do to better prepare physicians for ethical quagmires?

44. What is in place to guide all physicians? --Hippocratic Oath --System of Medical Ethics --ACP Ethics Manual --Geneva Conventions --WMA and AMA guidelines

45. Framework of Ethics Respect for autonomy Beneficence – An obligation to act for the benefit of others – Intentionally take positive steps to help others. Non-maleficence – An obligation not to inflict harm on others – Intentionally refrain from actions that cause harm Justice

46. Preparation Read Be Informed Plan scenarios – EPWs, civilians, refugees, etc… Discuss issues with other physicians Discuss issues with non-physicians – Chaplains – Commanding Officer / XO

47. Summary What should you do if placed in a conflict situation or experience “dual loyalty”? – No one should fault you for voicing ethical concerns – Approach your CO / XO – Remember you have a medical chain of command – If in doubt, do what is best for the EPW, unlawful combatant, or detainee

48. Summary Military medical ethics – Longstanding problem – Tougher than good medical care – Know the guidelines – Do your homework – Seek advice – Be prepared; it is your duty!

49. GTMO Case scenario #1 32 yo Afghani male with no known PMH or mental illness chooses to begin a hunger strike – Physician aware by the fourth missed meal – What are your duties and obligations to the patient? Water? B vitamins? – When does his life become endangered? – Should you participate in forced feeding?

50. GTMO Case scenario #2 Same patient as before: – Has a history of mental illness and has attempted suicide before. – Is part of a large group of prisoners urged by an “imman” to fight via hunger strike

51. GTMO Case scenario #3 Same patient as before: – The CO of the detention facility has told you that per directive the prisoner will be strapped in the feeding chair and assisted feeding will begin after nine missed meals. – You are told to monitor the patient and assist with tube placement.

52. GTMO Case scenario #4 You arrive in GTMO. 15 detainees are in a hunger strike All are being strapped into feeding chairs and being forced fed. – 10 do not resist (relieved to be fed) – 5 fight each time to avoid feeding You are told to supervise the process

54. Extra slides

55. Hippocratic Oath “exercise my art solely for the cure of patients, and will give no drug, perform no operation for a criminal purpose, even if solicited…”

56. ACP Ethics Manual 2005; 5 th Edition Relation of the Physician to Government Physicians must not be a party to and must speak out against torture or other abuses of human rights. Participation by physicians in the execution of prisoners except to certify death is unethical. Under no circumstances is it ethical for a physician to be used as an instrument of government to weaken the physical or mental resistance of a human being, nor should a physician participate in or tolerate cruel or unusual punishment or disciplinary activities beyond those permitted by the United Nations Standard Minimum Rules for the Treatment of Prisoners (90). Ann Intern Med. 2005;142:560-582. www.annals.org

57. Geneva Conventions Major revision after each World War. Most recent version signed by majority of world in 1949. – US ratified this convention in 1955 – It applies within the US military for… “…all cases of declared war or of any other armed conflict…even if the state of war is not recognized by one of [the parties to the conflict].”

58. Modern Four Conventions (1949) Convention I For the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field, Geneva, 12 August 1949: Sets forth the protections for members of the armed forces who become wounded or sick. Convention II For the Amelioration of the Condition of Wounded, Sick and Shipwrecked Members of Armed Forces at Sea,Geneva, 12 August 1949: Extends these protections to wounded, sick and shipwrecked members of naval forces. Convention III Relative to the Treatment of Prisoners of War, Geneva, 12 August 1949 lists the rights of prisoners of war. Convention IV Relative to the Protection of Civilian Persons in Time of War, Geneva, 12 August 1949: Deals with the protection of the civilian population in times of war.

59. The Two Protocols (1977) Protocol I Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts, 8 June 1977: Extends protection to victims of wars against racist regimes, wars of self determination, and against alien oppression. Protocol II Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of Non-International Armed Conflicts, 8 June 1977: Extends protection to victims of internal conflicts in which an armed opposition controls enough territory to enable them to carry out sustained military operations.

60. Protected Persons under the Conventions “Non-Combatants” – Civilians – Medical Personnel – The Wounded, Sick, or Dead – Enemy Prisoners of War – Parachutists Escaping Craft – Chaplains – Shipwrecked sailors

61. Civilians Treat Civilians Humanely Respect their customs and religion Do not use them as hostages or shields Protect Civilians from… – Violence and Insult – Sexual Assault – Pillage or reprisals No displacement – except in extreme cases and for protection GC Article 8, Article 54, and others

62. Medical Personnel Article 10: General Protection of Medical Duties “Under no circumstances shall any person be punished for carrying out medical duties compatible with medical ethics, regardless of the person benefiting therefrom.” Geneva Conventions

63. Duties Owed to Enemy Prisoners of War (EPWs) Duty to Respect: – Do not attack, kill, mistreat, or in any way harm a fallen and unarmed combatant. Duty to Protect: – Render care as the combatant’s condition requires. Duty to provide humane treatment: – Treat fallen combatants as one’s own wounded. There should be no adverse distinctions: – based on factors of gender, race, nationality, religion, or political opinions.

64. Obligations for humane treatment of EPWs Removal from combat zone Allow surrender Do not kill; and do safeguard from harm No coercion Provide medical care Don’t take personal property Allow religious practice Do not force EPWs to perform dangerous, humiliating, or war-related labor.

65. Detainee Medical Care EPWs: – We must provide medical and dental care Retained Personnel: – We must provide medical and dental care Civilian Internees: – We must provide medical and dental care Civilian Internees will, if possible, be moved to a civilian hospital, where treatment must be as good as that provided to the general population Based on Geneva Conventions

66. Torture “ The deliberate, systematic, or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason.” Tokyo Declaration, 1985 World Medical Association

67. Investigation of Detainee Deaths and Injuries A camp or hospital commander must appoint an officer to investigate and report each death or serious injury caused, or suspected to be caused, by “guards or sentries, another civilian internee, or any other person”. Geneva Conventions

68. Health providers and "unlawful combatants“ -- legal and ethical obligation to report or actively protest against such unjust treatment --Report to appropriate authorities Dual Loyalty Working Group

70. ASD-HA Principles: 1.Health care personnel charged with the medical care of detainees have a duty to protect their physical and mental health and provide appropriate treatment for disease. To the extent practicable, treatment of detainees should be guided by professional judgment and standards similar to those that would be applied to personnel of the US Armed Forces. 2. All health care personnel have a duty in all matters affecting the physical and mental health of detainees to perform, encourage, and support, directly and indirectly, actions to uphold the humane treatment of detainees. 3. It is a contravention of DoD policy for health care personnel to be involved in any professional provider-patient treatment relationship with detainees the purpose of which is not solely to evaluate, protect, or improve their physical and mental health.

71. ASD-HA Principles: It is a contravention of DoD policy for health care personnel: (a) To apply their knowledge and skills in order to assist in the interrogation of detainees in a manner that is not in accordance with applicable law; (b) To certify, or to participate in the certification of, the fitness of detainees for any form of treatment or punishment that is not in accordance with applicable law, or to participate in any way in the infliction of any such treatment or punishment. 5. It is a contravention of DoD policy for health care personnel to participate in any procedure for applying physical restraints to the person of a detainee unless such a procedure is determined in accordance with medical criteria as being necessary for the protection of the physical or mental health of the safety of the detainee himself or herself, or is determined to be necessary for the protection of his or her guardians or fellow detainees, and is determined to present no serious hazard to his or her physical or mental health.

72. ASD-HA Principles: 1. Medical Records: Accurate and complete medical records on all detainees shall be created and maintained in accordance with reference (b). 2. Treatment Purpose: Health care personnel engaged in a professional provider-patient treatment relationship with detainees shall not undertake detainee-related activities for purposes other than health care purposes. Such health care personnel shall not actively solicit information from detainees for purposes other than health care purposes. Health care personnel engaged in non-treatment activities, such as forensic psychology or psychiatry, behavioral science consultation, forensic pathology, or similar disciplines, shall not also engage in any professional provider-patient treatment relationship with detainees.

73. World Medical Association Established in 1947; response to WWII Independent organization Over eighty member organizations – AMA, BMA, etc… Created to ensure the independence of physicians Work for the highest possible standards of ethical behavior and care by physicians

74. World Medical Association http://www.wma.net/e/ethicsunit/resources.htm -- Published in 2005 --Free download on web --Free copies by mail

76. http://www.phrusa.org/healthrights/dual_loyalty.html

77. The Line Officers guide…

78. The lawyers guide…

79. ACP Ethics Manual 2005 5 th Edition Ann Intern Med. 2005;142: 560-582. www.annals.org

80. Hippocratic Oath Original (ancient version) Modern version Most medical schools in U.S. still give some form of this oath at graduation