Douglas Olsen is an associate professor at the Michigan State University College of Nursing in East Lansing and a contributing editor of AJN, where he regularly writes about ethical issues in nursing.
Nasal tubes, gravity feeding bags, and the liquid nutrient Ensure used in Guantanamo force-feeding/ image via Wikimedia Commons
The Miami Herald reported this week that a U.S. Navy nurse and officer refused to take part in force-feeding hunger-striking detainees at Guantanamo Bay.
There’s much we still don’t know about this story, but the force-feeding of prisoners at Guantanamo has been a contentious issue for some time. The practice has been compared by some to torture, and ethicists in the medical literature have urged the physicians involved to refuse to participate, while the U.S. government and President Barack Obama defend the practice on humanitarian grounds of preventing the deaths of the detainees.
Whether or not one feels that nurse participation in the force-feeding is justified, this officer, whose identity has not been released, appears to deserve the profession’s praise for taking a moral stand in an extraordinarily difficult circumstance. All nurses have the right of conscientious objection, of refusing to participate in practices that they find morally objectionable—assisting in abortions is another practice that some nurses have opted out of on moral grounds—and officers in the U.S. armed services are bound to consider the legality and morality of orders they carry out.
Much is at stake for this nurse. Not only do officers risk their careers when refusing an order on moral grounds, but they must breach a sacred principle of effective military operation: obedience to the chain of command except by an officer in extraordinary circumstances.
Further, the officer deciding to refuse an order must make this determination alone and accept severe consequences if the further consideration of the higher chain of command, the courts, or history does not support her or his assessment.
The relationship of military orders and nursing ethics as applied to force-feeding the Guantanamo detainees is complex. On the one hand, there are strong reasons to consider force-feeding unethical. In civilian practice, forcing any intervention on a patient with decision-making capacity is considered wrong even if the person’s life is at risk.
However, in addition to civilian nursing ethical considerations focused on patient benefit and rights, a military nurse also has legitimate concern for the mission. In addition, the force-feeding at Guantanamo appears, at present, to be legal—the courts considering the issue have specifically declined to issue orders stopping the practice.
The ethics issues are too involved to treat adequately in a blog post. Ann Gallagher (editor of Nursing Ethics, who once worked in the facility housing the Irish Republican Army hunger strikers who died in 1981) and I have considered the issues in greater depth, and an article is due for publication in the American Journal of Nursing this fall.
The consequences of this case are substantial—if the detainees’ right to protest by hunger strike and to refuse medical intervention is honored, as many suggest it should be, this means allowing them to die. Seen from such a perspective, to force-feed them is to deny these prisoners the right of self-determination—and to do so by providing them treatment that many people consider torture (see, for example, this video animation of force-feeding).
Let’s hope this nurse’s personal stand brings thoughtful debate of the issue to the public and helps us find a just solution for all.
You have to remember the patients rights…if they refuse food or medicineor any other treatment..that is their right….we cannot force that on them. If you do then you walk that fine line of abuse. I know of a nurse that offered a patient their medication three times and was fired for doing so because the patient refused..and by continuing to offer it..they viewed that as abuse. So in a sense the nurse ends up to be between a rock and a hard place. Always remember patient rights when making decisions for a patient.
Nurses have a moral and an ethical duty to exercise their judgment in the interests of those entrusted to their care. Decision-making about health care legally and ethically rests with the individual, unless the individual lacks the competency an capacity to make decisions. This nurse has honored the profession and clearly respects the social contract between the public and the profession; he may keep his license, but unfortunately he may lose his job. Work shouldn’t hurt; do no harm! I hope he has the best JAG for representation; and if the Navy needs nurses, they’d be hard pressed to find better in terms of honor, courage and commitment!
This is a prime example of why we should have a national nurses union. In my nursing career, I’ve neither been pro or anti in the union issue but these are definitely extraordinary times in which we need one loud, unified voice to speak up! This force feeding is in inhumane and a nurse should never be force to violate their morale code, an officer in the Navy or not.
Nurses are the hand and heart of compassionate care. Regardless of how others will judge or persecute her, she followed her conscience. I agree with Robert’s comment, maintaing humanity in our profession trumps all. She made the best decision she could for her patients, consequences be damned…that’s a real nurse.
Reminds me of Edith Cavell…
Thanks to everyone so far for keeping the conversation respectful and civil, both here and on our Facebook page, despite this being a tough issue.-Jacob, AJN blog editor/senior editor
In Maine we have a patients bill of rights and one of these rights is to refuse treatment even if the patient has dementia and decides on this course.What’s palliative care all about if it isn’t to address this. I spent 50 years in Nursing ,Operating room and 2 years at a Veterans home chronic care. Ethics? Do unto others as you would have done to you and refuse to do to others what you would not allow done to you.
It is a brave nurse indeed, and a very interesting article. Although the arguments re complex ones, I think the nurse may actually argue that working in Guantanamo Bay is not a ” mission” as such. It has been an installation for a number of years now, and houses prisoners–that being an ehtical debate in itself. I do think he/she is right in the choice not to prticiapate. Even though the prisoner is considered the enemy, the still have capacity to choose as individuals, and a breach of this right may yet come back to haunt military personnel who fail to recognise this. There are still clauses of geneva Convention adn medical ethics which may allow the choice.
I stand behind the Nurse. I would also refuse to force feed any competent patient. Having been a member of the Armed Services, I understand the UCMJ. That being said, I believe the oath I took when I became a RN takes priority. There has to be a point where being human takes precedence over following orders.
I cannot not imagine the predicament this nurse was/is in, but I applaud the decision based on what we all learned as nurses…do no harm. I do see ethical issues, but I am also aware of military rules. Where does one’s allegiance lie? Does the Commander in Chief’s orders supersede all else? Does disobeying an order automatically result in a court martial/a charge of treason?
I believe every person has the right to decide how they want to live. If the detainees choose to die from hunger, it is their choice. As an RN with 47 years of practice, I would find that difficult to watch. Another part of me thinks force feeding is a form of abuse.
This is a tough decision. One that makes me think more about the consequences of war….the dignified care of POWs. What really defines death with dignity and honor?
Thank you for sharing this story.