military medical ethics: force feeding; clear as mud? walter j. coyle, facp governor, navy chapter...

Military Medical Ethics:Military Medical Ethics:Force Feeding; Clear as Force Feeding; Clear as

Mud?Mud?

Walter J. Coyle, FACP

Governor, Navy Chapter

American College of Physicians

ObjectivesObjectives

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.

Cuba stays in the NewsCuba stays in the News

Questions of legality at GTMO

Medical complicity? Medical support of

interrogations? Role of Medical in

Forced Feeding

Most recent articleMost recent article

N Engl J Med 355;13 September 28, 2006

NEJM articlesNEJM articles

N Engl J Med 352;20 May 19, 2005

Prominent JournalsProminent Journals

N Engl J Med 2006;353:6-8

What I do know about GTMO?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

Medical Ethics in GTMOMedical 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

Medical Ethics at GTMOMedical Ethics at GTMO

What is a hunger strike?Does that differ from a death fast?Why do individuals or groups enter a

hunger strike?

Hunger StrikerHunger 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

Hunger StrikeHunger 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

Death FastDeath 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

Weapon of Last ResortWeapon 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 competentSignificant % have depression or PTSD

Dilemma of Balance Dilemma of Balance

Life

Autonomy

Turkish ExperienceTurkish Experience

Collective Prison hunger strikes: 1996Prisoners 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

Turkish Government ResponseTurkish 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

Turkish Medical Association Turkish Medical Association ResponseResponse

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

Other Famous Hunger StrikesOther 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

Gandhi (1896-1960)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

Russian DissenterRussian 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

Doctor-Patient RelationshipDoctor-Patient Relationship

Profoundly affected by a hunger strikeWhether 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

Military Medical EthicsMilitary Medical Ethics

Dual Loyalty

– Medical Oath

– Military Oath

“State-employed” physicians

– Occupational Health

– Prisons

Comrades in Arms

National security

Insert picture

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

Four Physician ResponsibilitiesFour 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

Ethical Dilemma in Hunger Ethical Dilemma in Hunger StrikesStrikes

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.

WMA guidelines on hunger strikeWMA guidelines on hunger strike

Declaration of Tokyo 1975

WMA guidelines on hunger strikeWMA guidelines on hunger strike

Declaration of Malta 1991

AMA guidelines on hunger strikeAMA guidelines on hunger strike

March 10, 2006

ACP guidelines on hunger strike: ACP guidelines on hunger strike: there are none, but…there are none, but…

Physicians must not be a party to and must speak outagainst torture or other abuses of human rights. Participationby physicians in the execution of prisoners except tocertify death is unethical. Under no circumstances is itethical for a physician to be used as an instrument of governmentto weaken the physical or mental resistance of ahuman being, nor should a physician participate in or toleratecruel or unusual punishment or disciplinary activitiesbeyond those permitted by the United Nations StandardMinimum Rules for the Treatment of Prisoners (90).

Ann Intern Med. 2005;142:560-582.

New DOD Guidelines 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

New DOD Guidelines 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

Assisted Feeding/Forced FeedingAssisted 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

Assisted Feeding/Forced FeedingAssisted 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

Dilemma of Balance Dilemma of Balance

Life

Autonomy

Forced Feeding: Legal Forced Feeding: Legal perspectiveperspective

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

Legal versus Ethical conflict:Legal versus Ethical conflict:Capital PunishmentCapital 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

Legal versus Ethical conflict:Legal versus Ethical conflict:Forced FeedingForced 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

The core of obligations for all armed The core of obligations for all armed conflictconflict

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”

Article 17Article 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

Ethics and youEthics 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

Ethics and ClarityEthics 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

What can we do to better What can we do to better prepare physicians for ethical prepare physicians for ethical

quagmires?quagmires?

What is in place to guide all physicians?

--Hippocratic Oath

--System of Medical Ethics

--ACP Ethics Manual

--Geneva Conventions

--WMA and AMA guidelines

Framework of EthicsFramework 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

PreparationPreparation

ReadBe InformedPlan scenarios

– EPWs, civilians, refugees, etc…Discuss issues with other physiciansDiscuss issues with non-physicians

– Chaplains– Commanding Officer / XO

SummarySummary

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

SummarySummary

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

GTMO Case scenario #1GTMO 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?


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


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.


You arrive in GTMO.15 detainees are in a hunger strikeAll 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

Extra slidesExtra slides

Hippocratic OathHippocratic 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…”

ACP Ethics Manual 2005; 5ACP Ethics Manual 2005; 5thth Edition Edition

Relation of the Physician to GovernmentPhysicians must not be a party to and must speak outagainst torture or other abuses of human rights. Participationby physicians in the execution of prisoners except tocertify death is unethical. Under no circumstances is itethical for a physician to be used as an instrument of government to weaken the physical or mental resistance of ahuman being, nor should a physician participate in or toleratecruel or unusual punishment or disciplinary activitiesbeyond those permitted by the United Nations StandardMinimum Rules for the Treatment of Prisoners (90).

Ann Intern Med. 2005;142:560-582. www.annals.org

Geneva ConventionsGeneva 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].”

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.

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.

Protected Persons under the Protected Persons under the ConventionsConventions

“Non-Combatants”

– Civilians

– Medical Personnel

– The Wounded, Sick, or Dead

– Enemy Prisoners of War

– Parachutists Escaping Craft

– Chaplains

– Shipwrecked sailors

CiviliansCivilians 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

Medical PersonnelMedical 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 ConventionsGeneva Conventions

Duties Owed to Enemy Prisoners of Duties Owed to Enemy Prisoners of War (EPWs)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.

Obligations for humane treatment of Obligations for humane treatment of EPWsEPWs

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.

Detainee Medical CareDetainee 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

TortureTorture

“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

Investigation of Detainee Investigation of Detainee Deaths and InjuriesDeaths 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

•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

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.

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.

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.

World Medical AssociationWorld Medical Association

Established in 1947; response to WWIIIndependent organizationOver eighty member organizations

– AMA, BMA, etc…Created to ensure the independence of

physiciansWork for the highest possible standards of

ethical behavior and care by physicians

World Medical AssociationWorld Medical Association

http://www.wma.net/e/ethicsunit/resources.htm

--Published in 2005

--Free download on web

--Free copies by mail

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

The Line Officers guide…The Line Officers guide…

The lawyers guide…The lawyers guide…

ACP Ethics Manual 2005ACP Ethics Manual 2005 5 5thth Edition Edition

Ann Intern Med. 2005;142:560-582. www.annals.org

Hippocratic OathHippocratic Oath

Original (ancient version)

Modern version Most medical schools

in U.S. still give some form of this oath at graduation

military medical ethics: force feeding; clear as mud? walter j. coyle, facp governor, navy chapter...

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