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Military Medical Ethics: Force Feeding; Clear as Mud?

Military Medical Ethics: Force Feeding; Clear as Mud?. Walter J. Coyle, FACP Governor, Navy Chapter American College of Physicians . Objectives. Review the definitions of hunger strike and hunger strikers.

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Military Medical Ethics: Force Feeding; Clear as Mud?

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  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 Autonomy Life

  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 fasted/hunger struck over 14 times Never exceeded 21 days Was successful in achieving his agenda Powerful political tool Gandhi (1896-1960) 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 Autonomy Life

  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. 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 Ethics and you

  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 takepositive 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

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