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.
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.