NEJM: Glimpses of Guantanamo - Medical Ethics and the War on Terror

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New England Journal of Medicine, Volume 353:2529-2534, December 15, 2005, Number 24
http://content.nejm.org/cgi/content/full/353/24/2529?query=TOC (New England Journal of Medicine is allowing the general public to view this published article, w/o cost to readers)

Glimpses of Guantanamo — Medical Ethics and the War on Terror,
(by) Susan Okie, M.D.


On a rainy afternoon in mid-October 2005, a white bus climbed the brush-covered hills near Guantanamo Bay, Cuba, carrying a group of visitors to Camp Delta, the desolate spot on the island's southern coast where the U.S. military holds more than 500 prisoners captured in the war on terror. It rolled through the detention camp's stockade-style gate and turned onto the dirt track inside the outermost of three high fences. Like others in the small group of civilian doctors, psychologists, and ethicists visiting that day, I peered through the bus's windows, eager for a glimpse of detainees. Since our arrival in the morning, we had spent more than two hours in a hospital conference room on the naval base, listening to a briefing by Major General Jay W. Hood, the camp's commander, and questioning him and other officials about the interrogation and medical care of detainees, including the force-feeding of hunger strikers. At last, I thought, we were about to see the prisoners.

(Department of Defense Photograph of Detainees and Guards at a Medium-Security Facility, Guantanamo Bay, Cuba)

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(Department of Defense Photograph of Detainee Hospital Ward at Camp Delta, Guantanamo Bay, Cuba)

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The patients — nine in all, we were told — were invisible. They lay behind floor-to-ceiling curtains covering the bays of the 30-bed hospital. Guards standing before the curtains came to attention the moment I tried to edge closer. I had been told before the trip that we would probably be permitted to speak with patients, and I received various explanations for the change of heart: officials didn't want to give hunger-striking patients a forum for media attention; they feared that a patient who had assaulted a nurse the previous night might again become disruptive or violent; they were concerned about detainees' privacy. Had I known that I would not have access to prisoners, I might have declined the invitation to visit Guantanamo, as United Nations representatives have since done.

Captain John S. Edmondson, an emergency physician and the commander of the medical group that delivers the prisoners' care, told us that eight of the patients had been admitted for involuntary tube feeding, to treat the medical consequences of their prolonged hunger strike. We were told that 25 prisoners were on hunger strike that day (a decline from 131 on the anniversary of the September 11 attacks) and that 22 were being fed by nasogastric tube — most while in their cells. Some had continued to lose weight — as much as 30 percent of their original body weight — despite these tube feedings and had been admitted for monitoring, endocrinologic evaluation, and additional treatment. "They are all clinically stable" with albumin levels over 4 g per deciliter, said Edmondson, a dark-haired man who looked tired and careworn on the day we visited. The weight loss "does not pose a danger," he said.

Although many aspects of the U.S. military's handling of detainees during the war on terror have been justly criticized, it remains a point of pride among medical workers, security staff, and military leaders at Guantanamo that there have been no deaths among Camp Delta prisoners. Clearly, Hood hopes to maintain that record. "I will not allow them to do harm to themselves," he told us. The military's policy of tube feeding prisoners on hunger strike is controversial, and military health care providers are "screened" before deployment to Guantanamo "to ensure that they do not have ethical objections to assisted feeding," Edmondson told me. The World Medical Association declared in 1975 that prisoners who refuse food and whom doctors consider capable of understanding the consequences should not be fed artificially, and British authorities allowed hunger-striking members of the Irish Republican Army to starve to death in prison in 1981. Yet civilian doctors in U.S. federal prisons are permitted to order the force-feeding of hunger strikers, and some lawyers representing Guantanamo detainees concur with the policy of "assisted feeding" (as military officials prefer to call it) if it is judged medically necessary.

Ethicist Jonathan Moreno of the University of Virginia suggested in an interview that the ethical issues involved are complex. Detainees at Guantanamo, who are imprisoned in an isolated environment far from their families for an indefinite period, may not have the autonomy needed to make an informed decision to starve themselves. Moreno also noted that the military doctors, nurses, and medics responsible for the care of detainees have a strong interest in keeping them alive, which may render them unable to assess objectively the motives and decision-making process of hunger strikers.

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((photo inserted of) 10-French Dobhoff Nasogastric Tube.
According to the military, this type of soft, flexible tube is used for the tube feeding of hunger-striking detainees at Guantanamo)

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Psychiatrist Steven S. Sharfstein, the president of the American Psychiatric Association and a fellow visitor to Guantanamo, said there is consensus in his association that psychiatrists should not be involved in the interrogation of detainees at Guantanamo or in Iraq or Afghanistan. "There is great concern about when you depart from your physician role," he said. When a forensic psychiatrist examines a prisoner in a civilian jail, the psychiatrist first explains to the prisoner that the interview may not be to his benefit, and the prisoner is allowed to refuse. "With the detainee situation, there is none of that," Sharfstein said. "The process of interrogating detainees is, by its very nature, deceptive, and that's a major problem. . . . People have to interrogate, but it's really inappropriate to use psychiatrists."

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Susan Okie, M.D., is a contributing editor of the Journal.

An interview with Susan Okie, M.D., on Guantanamo Bay and medical ethics, can be heard at:
http://content.nejm.org/cgi/content/full/353/24/2529/DC1 (the interview is a supplement to Okie, S., Glimpses of Guantanamo — Medical Ethics and the War on Terror, N Engl J Med 2005;353(24):2529-34)
Rachel Gotbaum, the interviewer, is an independent producer based in Boston.
Download Interview MP3 (07:43, 3.5 mb)

References

▪ White J., Guantanamo desperation seen in suicide attempts. Washington Post. November 1, 2005:A1.
▪ Lewis NA., Red Cross finds detainee abuse in Guantánamo. New York Times. November 30, 2004:A1.
▪ Army Regulation 15-6: final report: investigation into FBI allegations of detainee abuse at Guantanamo bay, Cuba Detention Facility. (Accessed November 28, 2005, at http://www.defenselink.mil/news/detainee_investigations.html.)
▪ Intelligence interrogation. Field manual 34-52. Washington, D.C. Department of the Army. September 1992:3-18.
▪ Rumsfeld D. Counter-resistance techniques in the war on terrorism. Memorandum for the Commander, US Southern Command, April 16, 2003. (Accessed November 28, 2005, at: http://www.defenselink.mil/news/Jun2004/d20040622doc9.pdf.)(.pdf format, AdobeReader® required)

. . . more at http://content.nejm.org/cgi/content/full/353/24/2529?query=TOC (New England Journal of Medicine is allowing the general public to view the 12/15/05 published "perspective" article, w/o cost to readers)

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This is a "must read" article. Yes, despite it being in the New England Journal of Medicine, it's an easy read for layppl. And, it gives insight into WHAT is going on at Gitmo as to medical doctors that attend the "detainees." Dr. Okie, the author, writes as if she's writing a novel in attempts to draw in the readers. Good stuff, Dr. Okie, good stuff. Interesting comments from the American Psychiatric Association about medical ethics at Gitmo. Great resource material here when Freepers and other neo-cons try to poke us liberals/progressives in the eye!
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