[Ppnews] Guantanamo prison military document lays bare the brutality of force-feeding.
Political Prisoner News
ppnews at freedomarchives.org
Mon May 13 10:47:14 EDT 2013
*Al Jazeera's exclusive publishing of a key Guantanamo prison military
document lays bare the brutality of force-feeding.*
Jason Leopold <http://www.aljazeera.com/profile/jason-leopold-.html>Last
Modified: 13 May
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Guantanamo Bay, Cuba - Hunger striking Guantanamo prisoners who are
force-fed a liquid nutritional supplement undergo a brutal and
dehumanising medical procedure that requires them to wear masks over
their mouths while they sit shackled in a restraint chair for as long as
two hours, according to documentation obtained by Al Jazeera. The
prisoners remain this way, with a 61cm - or longer - tube snaked through
their nostril until a chest X-ray, or a test dose of water, confirms it
has reached their stomach.
At the end of the feeding, the prisoner is removed from the restraint
chair and placed into a "dry cell" with no running water. A guard then
observes the detainee for 45-60 minutes "for any indications of vomiting
or attempts to induce vomiting". If the prisoner vomits he is returned
to the restraint chair.
That's just a partial description of the "chair restraint system
clinical protocol" which medical personnel are instructed to follow when
administering a nutritional supplement to prisoners who have been
selected for force-feeding by Guantanamo Commander Rear Admiral John Smith.
Standard operating procedure
The restraint system, published here for the first time, along with
the feeding procedures policy, was contained in a newly revised Standard
Operating Procedure (SOP) for Guantanamo hunger strikers, obtained
exclusively by Al Jazeera from United States Southern Command
(SOUTHCOM), which has oversight of the joint task force that operates
The 30-page manual contains the most detailed descriptions to date
pertaining to the treatment of hunger strikers and prisoners who undergo
force-feedings. The SOP replaced a previous SOP issued in 2003 - revised
in 2005 - which was declassified several years ago by the Pentagon,
albeit with redactions. The new, unredacted policy obtained by Al
Jazeera went into effect March 5 - one month after Guantanamo prisoners
launched their protest over the inspection of their Qurans.
The procedure appears to have been revised and implemented in order to
deal with a mass hunger strike.
"Just as battlefield tactics must change throughout the course of a
conflict, the medical responses to GTMO detainees who hunger strike has
evolved with time," says the SOP. "A mass hunger strike was successfully
dealt with in  by utilising procedures adopted from the Federal
Bureau of Prisons and the approach delineated in this SOP.
"However, the composition of the detainee population, camp
infrastructure, and policies has all undergone significant change since
the initial version of this SOP... Much of the original instruction has
been retained in the form of enclosures. In the event of a mass hunger
strike, these enclosures can be utilised as they have proven efficacy
under mass hunger strike conditions."
The SOP notes that there are a number of prisoners who have been hunger
striking since 2005, who have "proven their determination", and whose
physical frailty have limited Guantanamo authorities' "options for
intervention". The document goes on to say, "in the event of a mass
hunger strike, isolating hunger striking patients from each other is
vital to prevent them from achieving solidarity".
On April 13, guards staged a predawn raid at the communal camp and
isolated more than 100 prisoners into single cells in an attempt to
bring an end to the protest.
<http://www.jhsph.edu/news/news-releases/2009/rubenstein.html>, a lawyer
at the Center for Public Health and Human Rights at the Johns Hopkins
Bloomberg School of Public Heath and the Berman Institute of Bioethics,
who reviewed the SOP document for Al Jazeera, said the revised
guidelines were troubling because they prohibit doctors and nurses from
acting independently and make clear that they are simply "adjuncts of
the security apparatus".
Indeed, the SOP says that in order to effectively manage hunger
strikers, a "close partnership" must exist between the Joint Medical
Staff and the Joint Detention Group security force. Rubenstein
characterised the relationship as "Orwellian".
"It is a very frightening idea that the medical staff is an adjunct of
the security force," Rubenstein said. "The clinical judgment of a doctor
or a nurse is basically trumped by this policy and protocol. Doctors are
not acting with the kind of professional medical independence. It's
clear that notwithstanding references to preservation of detainee health
in the policy the first interest is in ending the protests."
Rubenstein pointed out the SOP does not provide any direction to medical
personnel on how to deal with prisoner's who may be suffering from a
mental health condition.
Currently there are at least 27 prisoners who are being force-fed,
although some of the lawyers of the prisoners say the number is much higher.
The SOP says the Behavioral Healthcare Service (BHS) "will perform an
assessment of the mental and psychological status of the detainee, which
will be documented in the outpatient medical record ... BHS will
continue to regularly evaluate detainees who continue on a hunger strike."
"What's missing is the determination of capacity that is required by
international ethical guidelines as well as responsiveness to the
detainee's needs," Rubenstein said.
Prisoners are designated as hunger strikers, according to the SOP, if
they communicate, "either directly or indirectly (i.e. repeated meal
refusals) his intent to undergo a hunger strike or fast as a form of
protest or demand attention" or if they miss nine consecutive meals and
their ideal body weight falls below 85 per cent of either previous or
The SOP grants Guantanamo Cmdr. Smith - not physicians - with the final
authority to select hunger-striking prisoners for force-feedings.
Nurses, who according to the SOP conduct the feeds, and doctors, are
merely on hand to carry out the military's policy. Two weeks ago, 40
more nurses were sent to Guantanamo to assist with force-feedings.
"In the event a detainee refrains from eating or drinking to the point
where it is determined by the medical assessment that continued fasting
will result in a threat to life or seriously jeopardize health, and
involuntary feeding is required, no direct action will be taken without
the knowledge and written approval of the [Joint Task Force-Guantanamo]
Commander [Navy Rear Adm. John Smith, Jr.]," the document says.
Once prisoners are selected for force-feeding, Smith notifies the
Commander of SOUTHCOM, Marine Corps Gen. John Kelly, who then alerts top
officials at the Pentagon of the "necessity of initiating involuntary
feeding of a detainee."
Although the SOP says medical personnel will make "reasonable efforts"
to obtain consent from prisoners designated for force-feedings, the
document also notes that if consent cannot be obtained "medical
procedures that are indicated to preserve health and life shall be
implemented without consent from the detainee."
Rubenstein said the authority granted to Smith in which he chooses the
prisoners for force-feeding is concerning because it gives the commander
complete control over a medical procedure and medical decisions that
doctors should be responsible for.
In a letter sent to Secretary of Defense Chuck Hagel last month,
American Medical Association president Dr. Jeremy Lazarus said the
force-feeding procedure at Guantanamo, saying it "violates core ethical
values of the medical profession."
"Every competent patient has the right to refuse medical intervention,
including life-sustaining interventions," Lazarus said. "The AMA has
long endorsed the World Medical Association Declaration of Tokyo, which
is unequivocal on the point: 'Where a prisoner refuses nourishment and
is considered by the physician as capable of forming an unimpaired and
rational judgment concerning the consequences of such a voluntary
refusal of nourishment, he or she shall not be fed artificially.' "
The United Nations has condemned force-feeding as both a form of torture
and a breach of international law.
The revised SOP, however, says the Department of Defense and Joint Task
Force-Guantanamo (JTF-GTMO) "policy is to protect, preserve, and promote
life. This includes any serious adverse health effects and death from
Currently, there are 27 prisoners who are being force-fed. Long-term
hunger strikers who are force-fed, or as the SOP describes them,
"chronic enteral feeders," "are notified by the corpstaff that 'It is
time to feed.'"
Preparing for a mass hunger strike
The new hunger strike policy raises far more legal and ethical questions
about the force-feeding process than the policy the military issued in
2003 and revised two years later. Pentagon spokesman Lt. Col. Todd
Breasseale told this reporter on March 4 there was nothing questionable
about the way in which Guantanamo hunger strikers are treated.
Guantanamo officials, Breasseale said, "follow the Federal Bureau of
Prisons (BOP) protocols
hunger strike management and involuntary feeding of hunger strikers."
However, according to a report
<http://www.detaineetaskforce.org/read/#/244/>issued in April by the
nonpartisan The Constitution Project, "at least some federal prisons
handle hunger strikes very differently, and far less coercively, than at
For example, "The written federal guidelines for force-feeding make no
mention of restraints, and include several safeguards that are not in
place in Guantanamo," according to The Constitution Project, whose
members spent two years investigating the treatment of "war on terror"
prisoners. "Prison guidelines require the warden to notify a sentencing
judge of involuntary feeding, with an explanation of the background of
and reasons for involuntary feeding, as well as videotaping of
force-feeding. BOP requires that 'treatment is to be given in accordance
with accepted medical practice.' Accepted medical practice requires an
individualized assessment of the patient's situation that appears to be
absent at Guantanamo. It also requires individualized counseling of the
The newly revised SOP does not call for that type of counseling.
Moreover, according to The Constitution Project, "The BOP's written
policy on the use of restraints also conflicts with the restraint-chair
protocol at Guantanamo."
"Federal prisons are known to use restraint chairs for inmates who are
physically dangerous to themselves, other inmates, or guards, but at
most federal prisons, the chairs are apparently not used for forced
feeding," according to The Constitution Project's report. BOP
"regulations make no provision to routine or categorical use in cases,
regardless of an individual inmate's behavior, or the use of restraints
The use of restraint chairs to force-feed Guantanamo prisoners was
introduced in 2006 on the recommendation of a forensic psychologist and
three consultants from the BOP who visited the prison in 2005 following
a massive hunger strike. Human rights groups, who say the use of
restraint chairs are a form of punishment and an attempt to break hunger
strikes, have criticized its use.
Identifying Prisoners for Force-Fee ding
The SOP contains a "General Algorithm for a Hunger Strike," described in
the document as a "simplified outline for the medical management of
detainees on hunger strike."
It notes that after a prisoner is identified as a possible hunger
striker a medical officer performs a physical and the behavioural
healthcare service conducts a psychological evaluation. The prisoner is
then "counseled" about the dangers associated with a hunger strike.
"If detainee continues to hunger strike and clinical criteria for the
initiation of enteral feeding are met ...the detainee may be admitted to
the Detention Hospital or designated feeding block if medically stable.
Authorisation is obtained via chain-of-command from JTF-GTMO Commander
to begin enteral feeding."
Before being placed into the restraint chair, medical personnel offers
the prisoner one last chance to eat voluntarily. If the prisoner refuses
the "medical provider signs medical restraint order" to force feed the
prisoner and encourages him to use the restroom before he is shackled.
The guard force then "shackles detainee and a mask is placed over the
detainee's mouth to prevent spitting and biting," states the chair
restraint protocol. "Detainee is escorted to the chair restraint system
and is appropriately restrained by the guard force."
A 10 or 12 "French" size (3.3/3.6 millimeters in diameter) feeding tube
is then placed into the prisoner's stomach through his nostril. He is
given a topical anesthetic, such as viscous lidocaine for his nostril
"unless detainee refuses." A sterile surgical lubricant, such as olive
oil, is applied to the feeding tube.
"Placement of the feeding tube in the stomach is confirmed using" air
insufflation along with a stethoscope and a test dose of 10 milliliters
of water to ensure it reached the detainee's stomach.
"The feeding tube is secured to the prisoner's nose with tape and "the
enteral nutrition and water that has been ordered is started and flow
rate is adjusted according to detainee's condition and tolerance."
The SOP says a feeding can "be completed comfortably over 20 to 30
minutes," a claim disputed by Guantanamo prisoner Samir Naji al Hasan
Moqbel, who described in a widely read /New York Times /op-ed the
intense pain he experienced from being force-fed.
The administration of two powerful drugs, in addition to a wide range of
over-the-counter medication, further undercuts the assertion that
force-feeding can be completed comfortably in a half-hour or less. The
two drugs at issue, according to the force-feeding policy, are
Phenergan, which is used to prevent motion sickness, nausea, vomiting,
pain or as a sedative or sleep aid, and Reglan, which is used to treat
heartburn caused by acid reflux. Long-term use of Reglan has been known
to cause <http://drugs.com/reglan.html>the irreversible neurological
disorder, tardive dyskensia.
The SOP states that if a prisoner vomits or attempts to induce vomiting
after he is placed in a "dry cell" following the "nutrient infusion,"
his "participation in the "dry cell will be revoked and he will remain
in the restraint chair for the entire observation time period during
The SOP contains a separate protocol for dealing with prisoners who bite
their feeding tubes. That policy also belies claims in the document
about the ease of force-feeding a Guantanamo prisoner.
Indeed, according to the biting protocol, "If the detainee is able to
get the [enteral feeding] tube between his teeth, the RN [registered
nurse] shall...direct the guard staff to stabilize the detainee's head
in the midline position... Hold traction on the tube for as long as
necessary for the detainee to relax his jaw; then continue safe removal
of the tube. This may take considerable time."
Prisoners are not supposed to remain in restraint chairs for more than
One prisoner, Fayiz al-Kandari, a Kuwaiti who has been detained at
Guantanamo for more than 11 years and is currently being tube fed twice
a day said through his defense attorney, federal public defender Carlos
Warner, that the size of the tube being used on him - 10 French - is too
large and too painful.
"It takes several attempts to get the tube into the right place," Warner
told Al Jazeera. "Once it goes down his throat he has a difficult time
breathing. There's a gag reflex."
Lt. Col. Samuel House, a SOUTHCOM spokesman, told Al Jazeera "medical
professionals" who conduct the force-feedings, "carefully evaluate each
patient to determine the appropriate size of tube to use."
"A 10 [French] size feeding tube is tiny," House said. "It can be used
in children as young as six months and is the recommended size for
a one-year-old child according to standard pediatric references. Bottom
line: either a 10 or an 8 Nasal Gastric Tube is tiny and should not be a
big problem in an adult."
House added that all prisoners are given a choice at mealtime: "eat a
hot meal, drink the nutrient, or receive an enteral feed."
/Follow Jason Leopold on Twitter: *@JasonLeopold *
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