Ethical Dilemma of Dual Loyalty in Prison Health Care

Ethical Dilemma of Dual Loyalty in Prison Health Care



Ethical Dilemma of Dual Loyalty in Prison Health Care


            The recent cases of forced feeding in Guantanamo Bay prison in Cuba have brought to the fore the issues of human rights violations that prevail in the prison system. The military administration that runs the detention camp has legal foundations of initiating forced feeding of the inmates that want to starve themselves to achieve their political objectives. To the military administration, the preservation of order, security, and safety override any individual liberties of the prisoners that remain in their already constrained constitutional rights. Although the head of the detention camp orders the execution of forced feeding programs on striking inmate, the medical professional in the institution carries out the actual procedure.

             Hunger strikes are tools that are employed by the prisoners to bring their issues to the fore. The majority of the prisoners that engage in these undertakings are aware of the risks of exposing themselves. Nonetheless, they are ready to face the consequence towards airing their grievances. The ethical consideration arises in the medical practitioner’s duty to prioritize the best interests of their patient over any other directive is compromised. It follows that their engagement in actions that violate their primary care mandate is termed unethical by the World Medical Association.

            Given the complexity the legal particulars of forced feeding, the focus shifts on the onus of a medical practitioner to uphold universal medical considerations regardless their allegiance to a given institution. Medical practitioners face dual loyalty conundrum that pits their ethical mandate against their responsibility to the institution under whose authority they operate. Suggestions towards eliminating dual loyalty complications have suggested separating the healthcare obligations of the inmates from the prison administration. This will aid health practitioners to operate as autonomous medical entities with the best interest of the prisoners. The separation of tasks will aid fortify trust between primary caregivers and their patients. Procedures such as forced feeding will be handled by a separate public health official that is answerable to the prison’s administration. While the suggestion is valid and implemented in some countries, the questions of the priority in the allegiance of medical practitioners who are in the force persist. Similarly, practical instances of transcending the world of ethical guidelines are beyond the scope of present research. The paper attempts to clarify the mandate of healthcare practitioners in the service of both their military authorities and the unique circumstance that transcend ethical considerations.

Dual Loyalty

            Dual loyalty implies divided allegiance between to autonomous entities. Medical practitioners within the prison system are divided between fulfilling their obligations as a healthcare professional and obeying a formidable third party. The majority of medical professionals succumb to the latter. The practitioners are loyal to the institutional culture and feel obligated to protect public interest over the patient ones. It follows that they are used to medical operations other than the provision of primary care to the patients. The medical practitioners engage in urine tests, forensics, and capital punishment procedures that undermine their relationship with future patients when they require medical attention (Annas, 2006). Consequently, the patient’s may refuse treatment, as they perceive the health practitioner of a representative of the system that is undermining their liberties. As the trust between the medical practitioner and the patient is strained, the attempts to convince the patient that they face health risks will be interpreted as directives from the prison authority even when valid. Often, some of the untrained medical personnel are oblivious of the ethical dilemmas inherent in their service to the military.

Conscription into the military is currently voluntary. As such, the military health practitioners desired to serve their country. It follows that if they are convinced that preserving the life of an inmate will aid retrieve crucial information to protect the country, they will engage in forced feeding without regret (Annas, 2011). Military healthcare practitioners are answerable to both the state and the health regulatory bodies. The question of which authority takes precedence persists. Rather than determining the organization to comply with, the healthcare practitioners should limit their interactions with patients to that of a public health practitioner. An independent medical practitioner devoid of institutional pressure to comply and palpable to sanctions by health regulatory authorities is recommended.

Forced Feeding in Guantanamo Bay

            Force feeding procedures have been a common practice in prisons with the frequency escalating in the wake of the 9/11 terrorist attacks. As the bias that existed against any suspected terrorist proponent fades, the ethical realities of the practice have been accentuated (Benatar, 2008). The prevalent knowledge on the procedure likens it to torture owing to the complexity of the process and its execution by medical practitioners that champion the state or the military’s interest at the prisoner’s expense. The precedents in regards to hunger strikes highlight that a competent individual has a right to refuse medical treatment. The constrained constitutional rights of inmates, the destabilizing nature of a prison environment, and the nutritional deficiency of the protesters raise concerns on their competency validating the administration’s actions to an extent. It follows that the WMA law of Tokyo demands the solicitation of an independent medical practitioner to evaluate the mental and physical sate of the protesting inmates prior to initiating forced feeding programs. Guantanamo Bay has been observed to ignore the stipulations of the above law.

Procedure Concerns

The entral feeding process has several risks when done sequentially as is the case in Guantanamo Bay. In some situations, the nasopharyngeal tears and vomiting is induced. Medication to counter the nausea is given, which if taken consistently has the side effect of involuntary muscle twitching of the inmate (Nayak, 2006). The process is often irreversible. As the inmates will naturally resist the feeding during a hunger strike, the prison has emergency seats that restraint the prisoner’s limbs and head similar to those used during electrical executions. The overarching causes of the hunger strikes are the indefinite incarceration of the detainees devoid of any trial. The forced feeding commences after the 72-hour period when the patient is observed to foreign meals. The prison administration does not wait for the vital signs of the patients to deteriorate. The procedure of the medical personnel regular check up of the patients is within the ethics of healthcare. The problem emerges in revealing the findings to the prison administration. However, even an independent medical practitioner will have to state the competency status of the patient. If they recommend force-feeding in light of the incompetence of the prisoner, it does not imply that they are coerced as it is in the patients’ best interest.

Implementation Constraints

            The above inconsistencies in the application of changes in healthcare mandate to private healthcare personnel warrants study of implementation strategies. The complexity of dealing with a prisoner is not diminished by recruiting external assistance (Rubenstein & Annas, 2009). Rather than recommending that the medical practitioners are excluded from the forced-feeding process, they should be recruited for supervision purposes. They possess the relevant expertise to optimize safety in the procedure. The above is crucial as the practice is bound to continue even without the medical personnel to the prisoners’ detriment. Prisoner’s whose detention is based on an insanity plea require monitoring. The condition of their release is usually hinged on improvements in their mental status. Regardless of this fact, the medical practitioner’s loyalty, making such information public is in their patients’ best interest. Devoid of a law that empowers military medical personnel to operate autonomously, conformity to the prevalent institutional culture is inevitable (Rosenberg, 2014). Furthermore, apart from the medical ethical consideration, the moral standings of the respective practitioner are an independent factor. Uncovering the underlying biases, such as the belief that the prisoners’ cause is not genuine, motivates compliance by the medical practitioners. Implying that military medical personnel failure to adhere to universal codes of professional conduct is attributed to coercion is incorrect.


            The separation of health care obligations from the ministry of justice to the ministry of health will help alleviate ethical dilemmas that medical personnel in the service experience. Force-feeding is not innately sinister, only when poorly executed or done with malicious intent does become torture. The prisoners’ individual liberties are often infringed when it is for the greater good. Even when the prisoner is competent, the continued hunger strike is equivalent to a suicide attempt requiring immediate intervention. The permanent consultation services with independent healthcare institutions will only be viable if protected by legislation. The essence of medical military practitioner’s obligation to overarching martial authority should not be overlooked. The medical regulatory organizations should implement sanctions on autonomous health practitioners that default professional codes of conduct. They are unique circumstances that warrant the intervention of military medical personnel given the complexity of treating prisoners.


Annas, G. J. (2006). Hunger Strikes at Guantanamo-Medical Ethics and Human Rights in a “Legal Black Hole”. New England Journal of Medicine, 355 (13), 1377.

Annas, G. J. (2011). American Vertigo: “Dual Use,” Prison Physicians, Research and Guantanamo. Retrieved July 23, 2016, from  

Benatar, Solomon R. (2008). Dual loyalty of Physicians in the Military and in Civilian Life. Journal of Public Health, 102(3), 475-480.

Nayak, Meghana. (2006). Orientalism and ‘Saving’ US State Identity after 9/11. International Feminist Journal of Politics, 8.1: 42-61.

Rubenstein, L. S., & Annas, G. J. (2009). Medical ethics at Guantanamo Bay detention centre and in the US military: a time for reform. The Lancet, 374 (9686), 353-355. 

Rosenberg, Carol. (2014). Navy nurse refuses to force-feed Guantánamo captive. Retrieved July 26, 2016, from

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