Last week the largest nursing organization in the United States called for leniency  for a Navy nurse who has refused to participate in the force-feeding of detainees on hunger strike at Guantánamo Bay Prison.
Carol Rosenberg of the Miami Herald has reported that over 6,700 tube-feeding episodes have occurred at Guantánamo Bay, which along with evidence of participation in torture , have ignited debate about the ethical responsibilities of military clinicians.
Below, Berman Institute faculty members Leonard Rubenstein, JD, LLM, and Cynda Hylton Rushton, PhD, RN, FAAN, answer questions about the specific case and the ethical debate in general.
Leonard Rubenstein  served as co-chair of a task force for the Institute On Medicine As A Profession to examine the role of physicians and psychologists in detainee abuse, and was a lead author of the report : Ethics Abandoned: Medical Professionalism and Detainee Abuse in the War on Terror.
Cynda Rushton , the Bunting Professor of Clinical Ethics at the Berman Institute and the Johns Hopkins School of Nursing, has produced seminal work on issues of clinician moral distress  and ethical issues unique to nursing practice.
Why is there an ethical debate about force-feeding? Is it wrong if it is done to save a life?
Leonard Rubenstein: There is no serious debate within the health professions about ethical obligations of nurse and doctors in these situations, as there is broad acceptance of ethical duties including respect for patient autonomy, use of independent clinical judgment in addressing health issues faced by a patient, providing confidential advice and counseling concerning options, and supporting the patient concerning a patient’s decisions.
Further, framing the question as force-feeding, versus allowing someone to die, mischaracterizes hunger strikes. Prisoners typically engage in hunger strikes as one of the few outlets for political protest available to them, and almost without exception, the prisoner wants to achieve the objective, not to die. We have seen this recently in hunger strikes lasting 60 or more days involving more than 60 Palestinian prisoners in Israel and over 40 prisoners in Pelican Bay Prison in California. In those cases the medical staff examined the patient to determine competence of make decisions, provided medical care, counseled on options regarding nutrients to take while on the hunger strike, and respected the prisoner’s decisions. In exercising this role, they supported their patients and none of them died.
How would you characterize the Guantanamo Bay nurse’s refusal to force-feed hunger-striking detainees?
Cynda Hylton Rushton: The nurse’s refusal to participate in force-feeding of hunger striking detainees raises important ethical concerns about nurses’ right to conscientiously object to actions viewed as violating important ethical principles and norms. This case highlights the struggles that many nurses confront when their personal and professional values conflict with organizational or military demands and the ensuing moral distress they experience.
Rubenstein: The case also raises questions about the military’s conduct, whether it is acceptable to force its medical and nursing staff to participate in conduct that is unethical under the standards of the professions. The military should not put nurses and physicians in a position of having to engage in conscientious objection. Most military medical ethicists affirm that in the absence of military necessity health professionals should not be put in a position of having to abandon their professional obligations to serve military objectives.
Are the ethical challenges faced by military healthcare providers different from those faced by providers who care for the general public?
Rushton: Military nurses have dual obligations to uphold the ethical values of their profession (and thereby the patient’s interest) and their obligation to follow orders of commanders. These two obligations can create complex and morally distressing dilemmas, as nurses discern how to respond to situations such as orders to force-feed detainees. From a professional viewpoint, the ANA Code of Ethics applies to ALL nurses , regardless of their role, specialty, or geography—this includes the military.
Rubenstein: Ethical challenges for military nurses are exacerbated where the military uses its command and disciplinary structure to coerce them to deviate from ethical standards.
What options do nurses have when their personal and professional ethical values conflict with their duties?
Rushton: Regardless of the position one takes on the issue of force-feeding of hunger-striking detainees, nurses in all settings must be able to raise ethical concerns within a culture that supports open, honest and respectful dialogue and responsiveness. A culture of ethical practice is present when nurses are empowered and supported to raise their concerns, register their conscientious objections to practices that violate their ethical values, and request re-assignment without fear of reprimand, punishment or disrespect. The future of the nursing profession relies on a strong ethical foundation and a culture where ethical issues are confronted with respect and integrity.
Rubenstein: This is exactly right, and the problem here [with the case at Guantanamo] is that the military has not created the kind of culture that allows open discussion of ethical concerns much less deference to those concerns.
Are there any features at Guantanamo practices that add to the difficulties nurses face?
Rubenstein: Detainees report that the process of force-feeding is highly coercive, painful, and humiliating. Detainees are forced out of their cells by four guards through an often violent process called “forced cell extraction,” and strapped in a chair while being restrained in five places on their body. The feeding tube is forced up their noses and down their throats. According to military protocols, they are kept in the chair restraints each feeding for two hours. The restraints are used routinely, without any individual determination whether the detainee is likely to respond to tube feeding with violence; the nurse and doctor have no authority to remove the restraints if the detainee is cooperative.
At Guantanamo these practices raise the questions whether force-feeding is being used to punish detainees and whether command is compelling doctors and nurses to become complicit in punishment. Such practices have led the World Medical Association to describe force-feeding hunger strikes as a form of inhuman and degrading treatment .
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For more information:
Rushton recommends a recent article in the American Journal of Nursing , authored by Douglas Olsen and Ann Gallagher: “Ethical Issues for Nurses in Force-Feeding Guantánamo Bay Detainees.”
Rubenstein suggests reading a letter sent to President Barack Obama by physicians and bioethicists (including Berman Institute Director Ruth Faden ) regarding the force-feeding at Guantanamo Bay, as well as the task force report  mentioned above.