The American Medical Association and the Red Cross both condemn force-feeding as a form of torture. And yet, the U.S. government and the United Nations have both force-fed hunger-striking prisoners. The real problem? Most people probably don’t realize how complicated force-feeding is, and how much can go wrong.

Top image: U.S. Navy personnel holds up force-feeding tube used on prisoners in Guantanamo in 2013. AP Photo/Charles Dharapak

Widespread Condemnation

Force-feeding of rational prisoners has been a source of controversy for over a century. And recently, it has been a source of widespread condemnation by medical and human rights associations. Physicians for Human Rights and the American Medical Association both declared that, “forcible feeding is never ethically acceptable.” The World Medical Association released guidelines “concerning torture and other cruel, inhuman, and degrading treatment,” which specifically address force-feeding — and these guidelines were endorsed by the Red Cross. The guidelines stated that if a rational prisoner voluntarily refuses food, “he or she shall not be fed artificially.” The New England Journal of Medicine, in response to news about force-feedings at Guantanamo Bay, called on military physicians to refuse orders to force-feed detainees. In 2014, experts from the United Nations condemned force-feeding of prisoners, and recommended that the government of Israel not engage in the practice.

And yet, governments continue to force-feed prisoners. In 2006, the United Nations authorized the force-feeding of Vojislav Seselj, a Serbian paramilitary leader awaiting trial for war crimes. In response to protests, the U. N. noted that the European court of human rights had declared that force-feeding is not torture or inhuman if it is medically necessary and “if the manner in which the detainee is force-fed is not inhuman or degrading.”

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But avoiding “inhuman or degrading” treatment isn’t as easy as it looks. Advocates of force-feeding point out that medical tube feeding is an uncomfortable process, but not a torturous one. There is a difference, however, between the naso-gastric feeding of a willing patient and a forced procedure on someone who does not want to be fed.

The more you know about this process, the more you realize how much can go wrong — and each problem pushes the treatment closer to something that can be called “inhuman.”

Restraint chair used for enteral feeding at Guantanamo. Source: Department of Defense

Restraining The Subject

If someone moves around too much during the force-feeding process, it can be catastrophic — especially given today’s methods of forced nutrition. In the past, people were often force-fed through the mouth, which involved a block or a crank being placed between their teeth so their mouth could be pried open. This caused problems of its own. English and American suffragettes, who at the beginning of the 1900s went on hunger strikes in prison after being arrested during public protests, reported that their gums bled constantly from the repeated force-feedings. Feeding someone this way can break their teeth, and cut into their tongue. Very early force-feedings occasionally broke people’s jaws.

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Most current procedure guidelines for force-feedings, like the ones at Guantanamo Bay, specify that the procedure involves a naso-gastric tube, inserted into the nose. This reduces the danger of tooth, tongue, or jaw damage, as well as the danger, from biting, to the people doing the feeding. But the nose is a delicate structure — and force-feeding is rarely a delicate operation.

Improvised sessions, or ill-equipped sessions, can begin with a patient being shoved into a chair and held down by attendants. If the person being force-fed starts moving, the tube can cause nosebleeds and tissue damage, or attendants can break the nose during the struggle. Any facility that regularly performs these kinds of procedures has a chair with full restraints, and padding or a head strap to immobilize the head, but even slight movement can cause a great deal of pain.

To mediate the pain of a tube being forced down the nose, the tubes are lubricated, and most people are given pain-killers. These range from a topical nasal spray to Tylenol and Motrin. There’s also Mylanta, for heartburn, and Benadryl for watery eyes and runny nose after the feeding.

Placement of the Feeding Tube

No matter the circumstances, placing the feeding tube is tricky. It’s also vital. Doctors who have performed the procedure, even on willing patients, have noted that the tube can go in through the nose and out of the mouth, at which point it has to be pulled out and re-placed.

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The tube can also go down the windpipe, instead of the esophagus. And forcing food into someone’s lungs can cause pneumonia, a collapsed lung, or death. To make sure this doesn’t happen, the patient has to be given an X-ray, or some air has to be forced down the tube so the doctors can listen and confirm the correct placement.

This does not always work. Studies have shown that doctors can misidentify the placement of the feeding tube even when they see it in X-rays. Although people are monitored during the force-feeding, even a little food in the lungs can cause lasting and debilitating damage.

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Even if nothing goes wrong, the potential for problems ensures that force-feeding is a more complicated process than most people imagine. It takes time to make sure the tube is correctly placed, and that care will significantly extend the length of each session.

Starvation and Refeeding Syndrome

Force-feeding isn’t something that is done after one missed meal — a person who is force-fed has often been starving themselves for days. There are complications that come with feeding someone who has stopped eating entirely, one of which is called “refeeding syndrome.”

Feeding kit. Source: Department of Defense

When a person has starved themselves for days, their body metabolism has shifted. Shifting it back with sudden, large intakes of food can cause sudden releases of insulin. This, in turn, causes the body to snap up glucose and water, leading to dehydration, along with electrolytes like potassium and magnesium. These electrolytes were already depleted by starvation, and the lack of these electrolytes can cause everything from weakness and numbness to delirium and respiratory failure.

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According to the guidelines at Guantanamo Bay, to prevent refeeding syndrome, the person is first put on a regime designed to replenish their fluid levels with IV drips. They get blood tests for glucose and electrolyte levels. After about a day, the feeding tube is put in. They’re then fed slowly-increasing quantities of salt and water mixed with Pulmocare, a feeding supplement designed for people with lung disease. They start out with only a few hundred calories, moving to seven hundred calories after twelve hours, and twelve hundred calories per day after twenty-four hours. For the next day or so, their blood is tested and re-tested.

After forty-eight hours of Pulmocare, the person is switched to Boost Plus or Ensure nutritional drinks. They start at fifteen hundred calories a day, the supplement is increased over the next forty-eight hours to twenty-six hundred calories a day in order to force the person to regain some of the weight they lost during their fast. Eventually, the person is settled in at 1500 calories a day. The documents state that people who are being force-fed tend to be chronically underweight, but still healthy.

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Usually, after force-feedings, the person is put in a “dry room.” They are monitored to make sure that they don’t throw up. If they attempt to make themselves throw up, in subsequent feedings they’re not released from the chair until they’ve digested the food.

Involuntary Vomiting

Some people don’t have the option of not throwing up. Most accounts by suffragettes in prison note that they vomited instinctively, as soon as the tube was pulled out of them again. To prevent this, many people today are given a number of medications.

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There are a few medications for nausea. The most problematic of these is called Reglan. The generic name for Reglan is metoclopromide. It’s not dangerous for short term use, but if it’s taken for too long, it can cause an incurable disorder which forces someone to make repetitive and uncontrolled muscle movements. It also can cause a neurological disorder that causes delirium and muscle spasms — or it can simply cause depression.

The long-term use of metoclopramide is a possibility because there is, technically, no end date to force-feeding. One woman in India, Irom Sharmila, has been force-fed for over a decade, after going on a hunger strike to protest the killing by Indian military forces of 10 people at a bus stop.

A hunger-striker who’s being force-fed is not a patient. Rather, they’re being subjected to a long, painful, dangerous and humiliating procedure. They’re being forcibly restrained, sometimes for long periods of time. They’re most likely being medicated.

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You can debate the ethics of force-feeding, or argue that it’s justified in certain circumstances, but one thing should be clear: even though medical organizations have weighed in on the ethics of force-feeding and medical personnel have participated, this is not the same thing as a medical procedure.

[Sources: Revised Guantanamo Force-Feed Policy Exposed, Hunger Strikes And the Practice of Force-Feeding, Metoclopramide Hydrochloride, Have You Ever Tried to Force-Feed a Captured Human, The Importance of the Refeeding Syndrome, A Suffragette Describes What It Felt Like To Be Force-Fed, Suffragettes On Hunger Strike.]