Clueless Bioethicists at JAMA
Sometimes I think that to some bioethicists, it's all a mind game. The latest example is an article published in the Journal of the American Medical Association. Prisoners at Guantanamo Bay are on a hunger strike, and the authors are upset because army doctors are helping to force feed them. From the story:
Military doctors violate medical ethics when they approve the force-feeding of hunger strikers at the U.S. prison camp at Guantanamo Bay, says a commentary in a prestigious medical journal. The doctors should try to prevent force-feeding by refusing to participate, the three authors write in today's Journal of the American Medical Association.Let's not make this about the propriety of Guantanamo, but about the rights of prisoners and the duties of the government toward the imprisoned, generally. Prisoners are not fully autonomous deciders--to borrow a memorable Bush phrase--they are under the authority of the state. Moreover, the government has a duty to prevent suicide by prisoners. (Can you imagine the screaming if a Guantanamo prisoner succeeded in starving himself to death?) Thus, just as doctors should strive to revive a patient after a suicide attempt by hanging--which is medical treatment--the government has the duty to use the least intrusive methods available to keep inmates sufficiently nourished so that their lives are not at risk; thus nasal tubes but not surgically inserted abdominal tubes. And yes, doctors should help to make sure it is done correctly. And I would say this should apply to any prisoner who seeks to take his or her own life in any context."In medicine, you can't force treatment on a person who doesn't give their voluntary informed consent," said one of the authors, Dr. Sondra Crosby of Boston University. "A military physician needs to be a physician first and a military officer second, in my opinion."
This isn't to say that a patient should be required to have a heart bypass procedure, for example. But prisoners autonomy is not the same as those who are free. And they do not have the right to commit suicide. These bioethicists need to get out of their abstract ideals and into the real world.
Labels: Bioethics.
posted by Wesley J. Smith @ 8:08 AM
12 Comments
12 Comments:
This isn't to say that a patient should be required to have a heart bypass procedure, for example
Just curious, what would your opinion be if it was a prisoner who refused the bypass procedure, or some other medical treatment that would be necessary to prevent death by some congenital or contageous disease.
Hi, Jimmy the Dhimmi: I would say the patient has the right to refuse treatment. What he or she doesn't have is the right to commit suicide.
Would you care to say why you think that a prisoner doesn't have the right to commit suicide?
I would say that in some cases a prisoner might have a duty to commit suicide. If I were, say, a spy during the cold war and I were caught someplace that I didn't belong I might feel that I have a duty to commit suicide in order to protect those people whose lives depend on my secrecy. Would you also say that I don't have a right to take my own life?
We might have good reasons to attempt to stop the prisoner from suicide, but that doesn't mean that he doesn't have the right to try to bring about his own death.
A "right" is legally enforceable. I have a right to speak freely. I have a right to vote. If someone tries to stop me, I can go to court to ensure that my rights are respected.
People do not have a right to make themselves dead. They often have the power. So, the question becomes what our reaction to the desire should be.
I think I agree with you about rights. Do you require that a right be explicit, or is it enough that an action is "allowed as long as it is not outlawed?" For instance, I don't have an explicit right to do 50 jumping jacks, but if you were to restrain me from doing them I could take you to court and enforce my right to personal freedom.
The "right" of a prisoner (or anyone else) ought to exist in the same fashion. I don't think that an explicit endorsement of suicide is appropriate, but my reaction is that it is perfectly sensible for a prisoner to want to make themselves dead.
That which is not illegal, is by definition legal. But when it comes to suicide, that doesn't end it. In our society, the primary function of government is to protect the lives of its citizens. Suicide was once a crime, which was dumb. It was then seen as a mental health issue. So even though trying to kill oneself is not illegal, it can be prevented, by force if necessary. (Non lethal, of course, or what's the point?) So, if a prisoner wants to commit suicide, he or she is put on suicide watch and prevented. If I wanted to commit suicide and it became known, the state could (and in such cases, does) force treatment on people when it can be shown beyond a reasonable doubt that they are a threat to themselves.
It seems to me this is as it should be. There are a lot of people alive today, and glad of it, who wouldn't be if we did otherwise.
Thanks for coming by SHS.
Wesley,
I don't know how prevalent this is, but at least *one* state has adopted a policy of non-intervention with prisoners who are on hunger strikes. That state is Michigan.
If you recall, Jack Kevorkian threatened to go on a hunger strike if convicted in the killing of Thomas Youk. When he found out the Michigan prison officials would just let him starve, he called off his plans.
How do you argue that refusing a life saving treatment is not suicide when the patient knows that they will die without it? How is refusing a heart surgery different from refusing a feeding tube or a sandwich?
I go over this quite thoroughly in my books and articles. The U.S. Supreme Court ruled 9-0 that refusing life-sustaining treatment is not suicide. Indeed, if one dies, it is naturally caused from either injury or illness, and moreover, sometimes people who refused life sustaining treatment don't die.
Refusing a tuna sandwich, as you put it, when repeated over weeks, becomes an attempt at actual suicide no different than shooting yourself in the head. And just as we could try to prevent the pulling of the trigger, we can stop the person from causing death from malnurishment.
I realize that the blog has progressed into other subjects, but I feel compelled to tell you that this is a very unsatisfying answer.
I haven't read your books and articles, but as we were discussing it, the question is an ethical one and so your reference to the SC is not relevant. They deal in law and not ethics.
Also, without some sort of argument your claim that refusing food and refusing life saving treatment are analogous is not convincing, and I'm unsure why you think it should be.
This is the thing: I have answered your question repeatedly and in many forums, and those answers are not hard to find. But here are a few points: First, withdrawing life sustaining treatment leads to a natural death, suicide is an unnatural death, a killing if you will. Second, removing life sustaining treatment does not necessarily mean the patient will die, unless the "treatment" is sustenance. Karen Ann Quinlin, for example, lived 10 years after her respirator was removed. Killing, whether by self or others directly causes death, and in fact is a homicide. Third, the decision to apply or not apply medical measures is a medical decision. Suicide assistance is not a medical act.
I suppose our disagreement is a deep one which is rooted in differing definitions of "medicine" and "life." Thanks for indulging me.
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