Currently there are about 100 prisoners in Guantanamo Bay Detention on hunger strike (89 of whom have been determined to be innocent of accusations but not released and some of whom have been on hunger strike for more than 106 days) and an estimated “2,493 inmates in 15 state prisons are participating in a mass hunger strike.” (Democracy Now 7/17/13). At Gitmo, periodic hunger strikes have been going on for a number of years, prisoners are protesting unlawful imprisonment, cruel treatment and lack of transparency; many prisoners are being force fed. In California, prisoners are protesting the widespread and long term use of solitary confinement; as yet, no prisoners have been force fed. It is unethical and a violation of prisoners human rights to force-feed by Nasal gastric tube. Military and prison doctors who participate in this activity do so in direct violation of medical ethics. Using the format and method of Thomas Aquinas – I wish to examine why it is always unethical to force feed hunger strikers.
Question: Is it ever ethical to force feed hunger strikers to keep them alive?
Objection 1: Hunger Strikers are suicidal; therefore it is wrong to allow them to commit suicide.
Objection 2: The United States government has a responsibility to keep them alive, therefore they must force feed prisoners rather than allow them to possibly die.
Objection 3: As prisoners, the hunger strikers no longer have the freedom to make their own choices; therefore it is within the rights of the government to force feed them.
Objection 4: Feeding by nasal gastric tube is a medical procedure and therefore not “punishment,” “cruel,” or “torture” when administered by competent medical staff.
On the Contrary: According to the World Medical Association, “Forcible feeding is never ethically acceptable. Even if intended to benefit, feeding accompanied by threats, coercion, force or use of physical restraints is a form of inhuman and degrading treatment.”
Response: I answer that it is always unethical to force feed hunger strikers. Based upon the Universal Declaration of Human rights and international decrees on the treatment of prisoners, it is unethical and unjust for the United States government to force feed prisoners in their facilities. Prisoners retain basic autonomy over medical care and the right to refuse food, and medical treatment.
The World Medical Association and the American Medical Association clearly hold that hunger strikers are NOT suicidal. A hunger strike is defined as refusal of food for a period of 9 days as a means of protest. Death is not intended; however, the possibility of death is accepted by those engaging in prolonged hunger strikes.
Hunger strikes are always controversial. And, as history notes, the effectiveness of hunger strikes as a method of protest has been mixed and force feeding comes up as a perennial problem. When women were imprisoned during the Suffrage movement, they used hunger strikes as a means of protesting their unlawful imprisonment and the US government used force feeding as a punishment attempting to break the hunger strike, an episode depicted in the HBO docudrama Iron Jawed Angels. Hunger strikes are a legitimate and rational form of non violent protest and civil disobedience. When directed as a means of protest seeking attention of the wider society, hunger strikes have proven to be effective in some cases. Perhaps the 2 most famous modern hunger strikers were Gandhi and Bobby Sands (IRA prisoner).The British authorities responded to these hunger strikers in radically different ways.
Gandhi used hunger strikes as an effective tool of protest British colonialism. He was not suicidal but demonstrated a clear acceptance of death as a possibility. Gandhi’s resolve was unquestioned and his death was an outcome feared by those against whom he made his demands. “Bombay, 1932. After eight months in prison, Mohandas Karamchand Gandhi begins a hunger strike in protest of British support of a new Indian constitution that would condone separate political representation for India’s lowest social caste — otherwise known as the “untouchables.” British authorities did not want Ghandi to die for fear of broader protests. His hunger strike lasted 21-days. It is not unreasonable for prisoners to view hunger strikes as a legitimate and effective means of nonviolent protest.
It is also a means of nonviolent protest undertaken with full knowledge of the possibility of death. In 1981 Bobby Sands and eight other Provisional IRA prisoners went on hunger strike demanding to be recognized as political prisoners. Recently a survivor of the IRA hunger strike explained, “Our hunger strike was borne out of desperation. We had spent five years in complete and total isolation, locked up 24 hours a day. During those five years our political representatives had been trying to make a case for the reforms within the prison and, at the end of the process, it wasn’t coming—the brutality was getting worse. We were trying to bring the H Blockto an end “ With Thatcher’s government refusing to give into their demands, after 66 days on hunger strike – Bobby Sands died. The Provisional IRA hunger strike was directed at drawing attention to the prison conditions, as well as political demands within the context of a contested Northern Ireland. The situation in Northern Ireland continued to erupt in violence after Sands’ death.
Each of these highlights an aspect of hunger strikes relevant to today’s context. With Gandhi, we see the use of hunger strikes as an effective tool of civil disobedience and non violent protest. In Bobby Sands, we find an example of wider repercussions which lead governments to fear hunger strikes and engage in force feeding. However, a hunger strike is a legitimate form of nonviolent protest. Similar to civil disobedience, individuals have the right to protest unjust laws in non-violent ways and have their autonomy protected. Just as civil disobedience comes with the possibility of imprisonment; hunger strikes come with the possibility of death. That individuals are in prison and therefore have their freedom of movement restricted does not negate their autonomy over medical decisions. International law maintains that prisoners of sound mind retain the autonomy over medical decisions and therefore have the legitimate authority to refuse feeding by NG tube.
Reply to Ad 1: Since prisoners retain authority over medical decisions and by definition, a prisoner on hunger strike is not medically classified as suicidal, it is not ethical to force feed them against their will. Even when death is an imminent possibility, they are not considered suicidal. The question rests upon a medical diagnosis of sound mind upon entering hunger strike, after that their wishes should be respected as any other patients written instructions would be respected.
Reply to Ad 2: While the government is responsible for prisoners within their jurisdiction, this does not authorize the government to force feed prisoners, against their will. In particular, in cases where the protests relate to conditions within the prison itself, the primary responsibility of the state is to just and humane conditions in accordance with domestic and international law within state facilities. Therefore it is unethical to force feed them, even if they may die without it.
Reply to Ad3: As stated above, international agreements recognize that prisoners of sound mind retain autonomy over medical decisions. Therefore it is unethical to force feed them.
Reply to Ad4: Use of a nasal gastric tube is a medical procedure mandated by a host of medical conditions. Patient’s level of discomfort is dependent upon physical condition, gag reflex, etc. Psychologically, use of this procedure without the consent of the patient creates significantly greater anxiety, fear, pain, and discomfort. The procedure itself is invasive and while administration by competent medical staff determines its safety, it does not negate concerns of “torture.” Recently, rapper Mos Def voluntarily underwent the practice to highlight the plight of hunger strikers at Guantanamo Bay. Therefore calling it a medical procedure does not obliterate questions of cruel and inhumane treatment.
“Hunger Strikers are suicidal…”
A more precise terminology might be helpful. While some hunger strikers do intend to fast to the death, others only intend to fast for a limited time.
Describing those fasting to the death as ‘suicidal’ is also a bit ambiguous. They are not suicidal in that they are aiming at their own death as a goal (i.e. an end). Nor are they suicidal in the sense that they are unreasonably reckless in disregarding the consequences of their actions. Rather, the strongest objection to their actions is that they are including their own potential death as a means to what they wish to achieve, and use of such means is not moral. (You perhaps ought to address this objection.)
“The United States government has a responsibility to keep them alive…”
Society as a whole has a responsibility to keep them alive. (I don’t that is excessive nitpicking, because it helps generalize the argument, avoids overfocusing on an amorphous entity, and helps remind us that we all share in this — even Catholic moral theologians and blog commenters.)
“The World Medical Association and the American Medical Association…”
And why should an appeal to some pronouncement of theirs be regarded as determinative for an argument? You’ve set up your argument along the lines of Aquinas, but he would have been appealing to prior authoritative Catholic teaching, or to Scripture, since both of those things are foundations for Aquinas. I think that making all the pronouncements of the World Medical Association and the American Medical Association as foundations for ethical arguments would not be a good idea at all (I’ve looked at some of them).
“…use of this procedure without the consent of the patient creates significantly greater anxiety, fear, pain, and discomfort…”
So it’s better to let them die instead? Really? (I can see such an argument working in the case of someone who is inevitably approaching the point of death. But when death is not inevitably approaching, I do not see how such an argument might work.)
Paccer thank you for your comments.
First, the objections are the primary arguments made by the United States Department of Defense for their policy of force feeding are: 1. they are suicidal and 2. we are responsible for them and therefore we have a responsibility to keep them alive. more precise definitions of those positions are not needed. it is not more complicated than that. those are the DOD arguments for the policy of force feeding. the United States government (on behalf of the United States citizen population) is the one force feeding them. Society bears responsibility for that, but the government has custody of them, they have been appointed as civil authority (in the domestic case) as responsible for prisoners and quite simply they are the ones feeding them. It isn’t an amorphous entity – it is a concrete entity acting….The united states military, a branch of the united states government IS force feeding hunger strikers.
By definition, to be on hunger strike (and not depressed, mentally ill, etc) a determination has been made that you are NOT suicidal. They are not suffering from an eating disorder or clinical depression if they are determined by competent medical professionals to be on hunger strike.
Force feeding is being done by MEDICAL DOCTORS who are subject to the agreed upon guidelines of the AMA and the World Medical Association. We have international agreements agreed upon for the treatment of prisoners. Those who are force feeding the hunger strikers are subject to these medical ethics standards as a basic point. The basic autonomy to make medical decisions is not under international law and medical ethics taken away from prisoners of sound mind. (Catholic moral theology would not come up with a different answer it is still always unethical to force feed a hunger striker but this argument is intended to be more general. As it is a violation of basic human rights.) As I tell my students, a medical decision you find unreasonable is not by itself enough to declare a patient incompetent – it is enough to ask more questions and have mental capacity evaluated. But, a decision you find unreasonable is not sufficient for doctors and nurses to declare a patient incompetent and force medical procedures on them. I have the right to refuse treatment. Doctors who violate AMA guidelines risk losing their license. Military doctors are engaging in unethical and torturous medical practice following military orders but expressly in violation of AMA code of conduct.
Would it have been right for the British to force feed Gandhi? To imprison Romero for his own protection, against his will? We have a long tradition within Catholic and Christian theology of accepting that death may be a result of the pursuit of justice — Hunger strikes are a legitimate means of non violent protest. Just like civil disobedience one must be prepared to go to jail. A hunger striker engages in the protest knowing that he or she might die. Death is not, at least not in a Catholic worldview, the ultimate evil to be avoided at all costs. Yes, it is better to let them die – as they are dying in protest not committing suicide. They have the right to engage in non violent protest of what they believe is an unjust imprisonment and treatment.
As a patient, I have the right to refuse medical treatment and it is established medical ethics, catholic theology, and international law that prisoners who are mentally competent retain this right. As a human being, I have the right to protest non violently within the parameters of my context – Prisoners cannot hold a rally to protest their unlawful imprisonment or inhuman conditions at the Pentagon/State House; however, hunger strikes are a legitimate and rational form of non violent protest at their disposal. And “we” as society have a moral obligation to respect that protest.
“Force feeding is being done by MEDICAL DOCTORS who are subject to the agreed upon guidelines of the AMA and the World Medical Association. “
The resolutions of neither of those organizations have legal power over doctors. What is the basis for your claim?
“We have international agreements agreed upon for the treatment of prisoners.”
Then point to the text of the legal agreement, and show how it is not being followed.
“As a patient, I have the right to refuse medical treatment…”
Not under Catholic moral theology. From the Ethical and Religious Directives for Catholic Health Care Services: “A person has a moral obligation to use ordinary or proportionate means of preserving his or her life.”
“…hunger strikes are a legitimate and rational form of non violent protest at their disposal…”
Self-inflicted violence is still violence. At the end of a fast to the death there is a dead body.
You also refer to a letter by Bishop Pates (which can be found here). It is an excellent letter.
of interest to readers:
In California – the Catholic Bishops have come out on the side of the objections of the hunger strikers and in opposition to the use of solitary confinement:
Statements from Bishop Pates on the unjust conditions at Guantanamo: