Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we seek an expert ruling.
Last week, you voted on force-feeding a prisoner on a hunger strike. Here are the results:
Is it ethical for the prison doctor to sedate Tony and then "feed" him through a nasogastric tube?
Yes: 12%
No: 88%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in with an excerpt from his new book, Who Says You're Dead?:
Hunger strikes have been used by protesters and prisoners for centuries, including celebrated fasts by female suffragettes in the early 20th century, Mahatma Gandhi during the struggle for Indian independence, and Irish Republicans in 1981. Prisoners often have minimal autonomy, and threatening self-starvation is one of the few means of civil disobedience available to them.
Many Americans are aware that the U.S. government forcibly fed so-called "enemy combatants" detained at Guantanamo Bay during the 2000s. Far fewer realize that similar techniques are used against ordinary prisoners in the U.S. criminal justice system. Although the issue drew some public attention in 2013 when U.S. District Court Judge Thelton Henderson granted prison doctors in California the authority to force-feed hunger-striking convicts, the face of the movement against such force-feeding for years was Connecticut inmate Bill Coleman.
Coleman, who refused food to protest what he believed was an unjust rape conviction, was strapped down regularly for involuntary tube feeds from 2008 to 2014. His strike ultimately ended when he was deported to his native England at the conclusion of his sentence.
Advocates for the legitimacy of force-feeding make two distinct sets of claims: First, they advance the welfare of the individual inmate. Society, they argue, has a right to prevent suicide -- and inmates who refuse food are merely engaged in prolonged attention-seeking suicide attempts. Even if self-starvation were permitted outside of prisons, inmates are an inherently vulnerable population whose very capacity to make their own decisions about such high-stakes matters as suicide are necessarily diminished. In the interest of the inmates themselves, doctors have a moral obligation to preserve their lives.
Second, force-feeding advocates claim that preventing such hunger strikes is essential for maintaining order in a complex and often dangerous penal system. Allowing inmates to starve themselves undermines the authority of corrections officials and places both prisoners and staff in danger.
Yet force-feeding, especially when the patient resists, is not a benign procedure. Both the American Medical Association and the World Medical Association have condemned the practice, which many human rights advocates regard to be a form of torture. Most medical professional organizations prohibit their members from participating.
Analogies are often drawn to the role of physicians in capital punishment. While doctors have dual loyalties, serving both patients and society, any significant entanglement of healthcare providers with law enforcement should require compelling justification.
Even if one believes that force-feeding or the death penalty is itself ethical, it does not necessarily follow that physicians should have a role.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College. Appel is the author of the new book, Who Says You're Dead? Medical & Ethical Dilemmas for the Curious & Concerned.
And check out some of our past Ethics Consult cases:
Keep Patient on Feeding Tube After Dementia Dx?
Can Pediatrician Fire Vaccine Refusers?
Should Christian Clinic Provide IVF to Lesbian Couple?
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